MEDICARE: KELLI J SIMMONS APRN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	364SA2200X	Adult Health Clinical Nurse Specialist	R183718-8	MN
2	364SA2200X	Adult Health Clinical Nurse Specialist	093545	MO

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P00104707	OTHER	MO	RR MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1336186048
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLI J SIMMONS APRN

Provider Business Mailing Address
First Line	:	1570 EUSTIS ST
Second Line	:	APARTMENT 133
City	:	LAUDERDALE
State	:	MN
Zip	:	55108-1260
Country	:	US
Telephone Number	:	651-646-0172
Fax Number	:

Provider Business Practice Location Address
First Line	:	420 DELAWARE STREET SOUTHEAST
Second Line	:	MAYO MAIL CODE 450
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55455
Country	:	US
Telephone Number	:	612-626-5919
Fax Number	:	612-625-4406

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/01/2006
Last Update Date	:	02/17/2010

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