Basic Information
| Provider Information | |||||||||
| NPI: | 1881925154 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MONTGOMERY | ||||||||
| FirstName: | KERI | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | NP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CREWS | ||||||||
| OtherFirstName: | KERI | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 6 WOODLAND ROAD | ||||||||
| Address2: | SUITE 304 | ||||||||
| City: | ST. HELENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 94574 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7079637200 | ||||||||
| FaxNumber: | 7079637203 | ||||||||
| Practice Location | |||||||||
| Address1: | 6 WOODLAND ROAD | ||||||||
| Address2: | SUITE 304 | ||||||||
| City: | ST. HELENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 94574 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7079637200 | ||||||||
| FaxNumber: | 7079637203 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/26/2010 | ||||||||
| LastUpdateDate: | 02/25/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 203144 | NC | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | C-APN.0000068-C-NP | CO | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | APN.0991663-NP | CO | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | 95012403 | CA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 207QA0505X | 95012403 | CA | Y | Allopathic & Osteopathic Physicians | Family Medicine | Adult Medicine |
ID Information
| ID | Type | State | Issuer | Description | 7005510 | 05 | NC | MEDICAID |