Healthcare Provider Details

I. General information

NPI: 1780535344
Provider Name (Legal Business Name): SHANETTKA SIMMONS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/09/2026
Last Update Date: 07/16/2026
Certification Date: 07/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2121 W TEMPLE ST
LOS ANGELES CA
90026-4915
US

IV. Provider business mailing address

2121 W TEMPLE ST
LOS ANGELES CA
90026-4915
US

V. Phone/Fax

Practice location:
  • Phone: 213-385-5100
  • Fax:
Mailing address:
  • Phone: 213-385-5100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberMPSSNOSDFM
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: