Healthcare Provider Details

I. General information

NPI: 1730812371
Provider Name (Legal Business Name): SHELBY SIMMONS NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHELBY TATAR

II. Dates (important events)

Enumeration Date: 07/01/2022
Last Update Date: 07/01/2022
Certification Date: 07/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1407 E MICHIGAN AVE
JACKSON MI
49202-3517
US

IV. Provider business mailing address

1407 E MICHIGAN AVE
JACKSON MI
49202-3517
US

V. Phone/Fax

Practice location:
  • Phone: 517-888-6348
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704321560
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: