Provider Demographics
NPI:1043501778
Name:MONTGOMERY, JUSTIN BERNARD (FNP-C)
Entity type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:BERNARD
Last Name:MONTGOMERY
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 MEDICAL DR
Mailing Address - Street 2:ATTN CENTERS FOR HEALTHY AGING
Mailing Address - City:LEBANON
Mailing Address - State:NH
Mailing Address - Zip Code:03756-1000
Mailing Address - Country:US
Mailing Address - Phone:603-650-5000
Mailing Address - Fax:
Practice Address - Street 1:1 MEDICAL DR
Practice Address - Street 2:ATTN CENTERS FOR HEALTHY AGING
Practice Address - City:LEBANON
Practice Address - State:NH
Practice Address - Zip Code:03756-1000
Practice Address - Country:US
Practice Address - Phone:603-650-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-28
Last Update Date:2014-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH052034-23363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1019890Medicaid
NH3082773Medicaid