Provider Demographics
NPI:1770065187
Name:MONTGOMERY, AUTUMN KATHRYN (FNP-C)
Entity type:Individual
Prefix:
First Name:AUTUMN
Middle Name:KATHRYN
Last Name:MONTGOMERY
Suffix:
Gender:F
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 1:5534 SAINT JOE RD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46835-3328
Mailing Address - Country:US
Mailing Address - Phone:317-670-6794
Mailing Address - Fax:
Practice Address - Street 1:3518 S LAFOUNTAIN ST
Practice Address - Street 2:
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46902-3803
Practice Address - Country:US
Practice Address - Phone:765-453-4667
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-31
Last Update Date:2024-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71008480A363LF0000X
FL11002221363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN71008480AOtherAPRN PRESCRIPTIVE AUTHORITY