1760771034 NPI number — MRS. AMANDA MARIE SIMONSON LADC

Table of content: MRS. AMANDA MARIE SIMONSON LADC (NPI 1760771034)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760771034 NPI number — MRS. AMANDA MARIE SIMONSON LADC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SIMONSON
Provider First Name:
AMANDA
Provider Middle Name:
MARIE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LADC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SIMONSON
Provider Other First Name:
AMANDA
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1760771034
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/13/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
38873 14TH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORTH BRANCH
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55056-6079
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-401-3068
Provider Business Mailing Address Fax Number:
651-674-2534

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
38873 14TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NORTH BRANCH
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55056-6079
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-401-3068
Provider Business Practice Location Address Fax Number:
651-674-2534
Provider Enumeration Date:
04/07/2011

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: 101YA0400X , with the licence number:  303037 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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