Healthcare Provider Details

I. General information

NPI: 1942178058
Provider Name (Legal Business Name): RAE LYNN SIMMONS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/29/2025
Last Update Date: 03/26/2026
Certification Date: 03/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

966 12TH ST SE STE 130
SALEM OR
97302-2860
US

IV. Provider business mailing address

966 12TH ST SE STE 130
SALEM OR
97302-2860
US

V. Phone/Fax

Practice location:
  • Phone: 503-837-6395
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0050882
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: