Healthcare Provider Details

I. General information

NPI: 1568428647
Provider Name (Legal Business Name): WINNIE SUE SIMMONS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2006
Last Update Date: 11/03/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

798 SECOND AVE
MABEN MS
39750-8761
US

IV. Provider business mailing address

798 SECOND AVE
MABEN MS
39750-8761
US

V. Phone/Fax

Practice location:
  • Phone: 662-263-5900
  • Fax: 662-263-4132
Mailing address:
  • Phone: 662-263-5900
  • Fax: 662-263-4132

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number07362
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: