1710842992 NPI number — MRS. SHONTAY LATRESE SIMMONS PMHNP-BC

Table of content: MRS. SHONTAY LATRESE SIMMONS PMHNP-BC (NPI 1710842992)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710842992 NPI number — MRS. SHONTAY LATRESE SIMMONS PMHNP-BC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SIMMONS
Provider First Name:
SHONTAY
Provider Middle Name:
LATRESE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PMHNP-BC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1710842992
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/19/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
223 S 13TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAGINAW
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48601-1837
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
989-714-7299
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
223 S 13TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAGINAW
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48601-1837
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
989-714-7299
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/19/2025

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LP0808X , with the licence number:  4704308911 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2025 www.npivalidator.com