MEDICARE: YVONNE DECARLO SIMMONS

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	3747A0650X	Attendant Care Provider

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	B9238015	OTHER	CA	DRIVER LICENSE

General Provider Information

NPI Number	:	1487290904
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	YVONNE DECARLO SIMMONS

Provider Business Mailing Address
First Line	:	3022 FRANKLIN AVE
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92113-1415
Country	:	US
Telephone Number	:	619-709-7817
Fax Number	:

Provider Business Practice Location Address
First Line	:	3022 FRANKLIN AVE
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92113-1415
Country	:	US
Telephone Number	:	619-709-7817
Fax Number	:

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

Provider Enumeration Date	:	11/19/2019
Last Update Date	:	11/19/2019

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