Healthcare Provider Details

I. General information

NPI: 1609192798
Provider Name (Legal Business Name): SIMONE ALEXANDRA HURST
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/14/2010
Last Update Date: 04/14/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

553 PLAZA CIR
LITCHFIELD PARK AZ
85340-4930
US

IV. Provider business mailing address

553 PLAZA CIR
LITCHFIELD PARK AZ
85340-4930
US

V. Phone/Fax

Practice location:
  • Phone: 623-535-6066
  • Fax:
Mailing address:
  • Phone: 623-535-6066
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251300000X
TaxonomyLocal Education Agency (LEA)
License NumberSLPA6625
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: