Healthcare Provider Details

I. General information

NPI: 1780145284
Provider Name (Legal Business Name): KENNETH SIMMONS RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2019
Last Update Date: 03/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1310 24TH AVE S
NASHVILLE TN
37212-2637
US

IV. Provider business mailing address

224 CURD RD
MOUNT JULIET TN
37122-3072
US

V. Phone/Fax

Practice location:
  • Phone: 615-873-8040
  • Fax:
Mailing address:
  • Phone: 206-605-4345
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License NumberRN60566456
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: