Healthcare Provider Details

I. General information

NPI: 1740133115
Provider Name (Legal Business Name): BERNITA NICOLE SIMMONS FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/17/2026
Last Update Date: 02/17/2026
Certification Date: 02/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

171 HARVEY CIR
CANTON MS
39046-4557
US

IV. Provider business mailing address

171 HARVEY CIR
CANTON MS
39046-4557
US

V. Phone/Fax

Practice location:
  • Phone: 662-571-7936
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number123456789
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: