Healthcare Provider Details

I. General information

NPI: 1063195543
Provider Name (Legal Business Name): KEVIN SIMMONS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/10/2023
Last Update Date: 12/20/2023
Certification Date: 12/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

264 N HIGHLAND SPRINGS AVE STE 1B
BANNING CA
92220-3045
US

IV. Provider business mailing address

264 N HIGHLAND SPRINGS AVE STE 1B
BANNING CA
92220-3045
US

V. Phone/Fax

Practice location:
  • Phone: 951-769-7191
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95025928
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: