Healthcare Provider Details

I. General information

NPI: 1912345372
Provider Name (Legal Business Name): MISS TANDRA LAMIKIA SIMMONS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/07/2013
Last Update Date: 10/24/2022
Certification Date: 10/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 NW 8TH AVE STE A2
GAINESVILLE FL
32601-5000
US

IV. Provider business mailing address

PO BOX 358774
GAINESVILLE FL
32635-8774
US

V. Phone/Fax

Practice location:
  • Phone: 352-258-3450
  • Fax: 352-379-5502
Mailing address:
  • Phone: 352-258-3450
  • Fax: 352-373-7818

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number689678296
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: