1770674830 NPI number — MRS. SUSAN G SIMMONS RN, QMRP, QMHP

Table of content: MRS. SUSAN G SIMMONS RN, QMRP, QMHP (NPI 1770674830)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770674830 NPI number — MRS. SUSAN G SIMMONS RN, QMRP, QMHP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SIMMONS
Provider First Name:
SUSAN
Provider Middle Name:
G
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
RN, QMRP, QMHP
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:
1770674830
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
RR 1 BOX 308
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CAVE IN ROCK
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62919-9770
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-285-3361
Provider Business Mailing Address Fax Number:
618-285-3362

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
RR 1 BOX 99AA
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GOLCONDA
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62938-9619
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-285-3361
Provider Business Practice Location Address Fax Number:
618-285-3362
Provider Enumeration Date:
09/27/2006

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: 163W00000X , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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