Healthcare Provider Details

I. General information

NPI: 1265820625
Provider Name (Legal Business Name): SANDREA SIMMONS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

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

III. Provider practice location address

13937 BRADY
REDFORD MI
48239-2820
US

IV. Provider business mailing address

13937 BRADY
REDFORD MI
48239-2820
US

V. Phone/Fax

Practice location:
  • Phone: 313-915-8544
  • Fax: 313-472-5495
Mailing address:
  • Phone: 313-915-8544
  • Fax: 313-472-5495

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number4703110047
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: