Healthcare Provider Details

I. General information

NPI: 1902289879
Provider Name (Legal Business Name): BRIDGETT SIMMONS APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2015
Last Update Date: 01/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10150 E NORTH LAKE DR
NEWTON IL
62448-3461
US

IV. Provider business mailing address

10150 E NORTH LAKE DR
NEWTON IL
62448-3461
US

V. Phone/Fax

Practice location:
  • Phone: 217-343-0948
  • Fax:
Mailing address:
  • Phone: 217-343-0948
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209012911
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363LX0106X
TaxonomyOccupational Health Nurse Practitioner
License Number209012911
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: