Healthcare Provider Details

I. General information

NPI: 1679894117
Provider Name (Legal Business Name): JENNIFER L SIMONS CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2010
Last Update Date: 09/08/2022
Certification Date: 09/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14700 LAKE SHORE DR
CHARLEVOIX MI
49720-1999
US

IV. Provider business mailing address

14700 LAKE SHORE DR
CHARLEVOIX MI
49720-1999
US

V. Phone/Fax

Practice location:
  • Phone: 231-547-4024
  • Fax:
Mailing address:
  • Phone: 231-547-4024
  • Fax: 231-547-8088

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number4704246607
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: