Healthcare Provider Details

I. General information

NPI: 1710842992
Provider Name (Legal Business Name): SHONTAY LATRESE SIMMONS PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/19/2025
Last Update Date: 09/08/2026
Certification Date: 09/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1485 M 139
BENTON HARBOR MI
49022-5711
US

IV. Provider business mailing address

223 S 13TH ST
SAGINAW MI
48601-1837
US

V. Phone/Fax

Practice location:
  • Phone: 269-925-0585
  • Fax:
Mailing address:
  • Phone: 989-714-7299
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number4704308911
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: