Healthcare Provider Details

I. General information

NPI: 1316856537
Provider Name (Legal Business Name): KEREEN SEMONE WALLER SIMPSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/03/2026
Last Update Date: 09/03/2026
Certification Date: 09/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1106 NORTH AVE
BRIDGEPORT CT
06604-2710
US

IV. Provider business mailing address

PO BOX 185023
HAMDEN CT
06518-0023
US

V. Phone/Fax

Practice location:
  • Phone: 475-225-8071
  • Fax:
Mailing address:
  • Phone: 475-221-6620
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number144326
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: