Healthcare Provider Details

I. General information

NPI: 1811936545
Provider Name (Legal Business Name): KENDELL ANN SIMM PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2006
Last Update Date: 05/07/2026
Certification Date: 05/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6615 COMANCHE ST
BONNERS FERRY ID
83805
US

IV. Provider business mailing address

6615 COMANCHE ST
BONNERS FERRY ID
83805
US

V. Phone/Fax

Practice location:
  • Phone: 208-267-1718
  • Fax: 208-267-9197
Mailing address:
  • Phone: 208-267-1718
  • Fax: 208-267-9197

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA1467
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA12083
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: