Provider Demographics
NPI:1447896956
Name:MONTGOMERY, SYDNEY NICOLE
Entity type:Individual
Prefix:MS
First Name:SYDNEY
Middle Name:NICOLE
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 MEDICAL CENTER BLVD STE 250
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30046-3402
Mailing Address - Country:US
Mailing Address - Phone:770-979-4700
Mailing Address - Fax:770-979-1060
Practice Address - Street 1:500 MEDICAL CENTER BLVD STE 250
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-3402
Practice Address - Country:US
Practice Address - Phone:770-979-4700
Practice Address - Fax:770-979-1060
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-19
Last Update Date:2022-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN259595163WX0003X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WX0003XNursing Service ProvidersRegistered NurseObstetric, Inpatient
Provider Identifiers
StateIdentifier IDID TypeIssuer
15385033OtherCAQH
GA003256365Medicaid