Healthcare Provider Details

I. General information

NPI: 1174193973
Provider Name (Legal Business Name): JEAN MACLY SAINT-SIMON ARNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/25/2021
Last Update Date: 03/04/2024
Certification Date: 03/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

483 N AVIATION BLVD BLDG 210
EL SEGUNDO CA
90245-2808
US

IV. Provider business mailing address

483 N AVIATION BLVD BLDG 210
EL SEGUNDO CA
90245-2808
US

V. Phone/Fax

Practice location:
  • Phone: 310-653-6679
  • Fax:
Mailing address:
  • Phone: 310-653-6679
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11013645
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: