Healthcare Provider Details

I. General information

NPI: 1790203552
Provider Name (Legal Business Name): LATOYA ANN SIMON NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2017
Last Update Date: 12/11/2025
Certification Date: 12/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1780 OLD 41 HWY NW
KENNESAW GA
30152-4428
US

IV. Provider business mailing address

PO BOX 22239
NEW YORK NY
10087-0001
US

V. Phone/Fax

Practice location:
  • Phone: 872-231-3162
  • Fax: 702-977-1496
Mailing address:
  • Phone: 702-899-0595
  • Fax: 702-977-1496

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN190977
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: