Healthcare Provider Details

I. General information

NPI: 1407932254
Provider Name (Legal Business Name): PAMELA MARIE SIMOT ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

66 8TH AVE
FRUITPORT MI
49415-9664
US

IV. Provider business mailing address

66 8TH AVE
FRUITPORT MI
49415-9664
US

V. Phone/Fax

Practice location:
  • Phone: 616-604-6540
  • Fax:
Mailing address:
  • Phone: 616-604-6540
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: