Healthcare Provider Details

I. General information

NPI: 1609806256
Provider Name (Legal Business Name): EDWIN SIMON NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2006
Last Update Date: 01/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2004 HWY 47 N
WHITE BLUFF TN
37187-4100
US

IV. Provider business mailing address

2004 HWY 47 N
WHITE BLUFF TN
37187-4100
US

V. Phone/Fax

Practice location:
  • Phone: 615-797-3646
  • Fax: 615-797-4055
Mailing address:
  • Phone: 615-797-3646
  • Fax: 615-797-4055

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPN6734
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: