Healthcare Provider Details

I. General information

NPI: 1134742885
Provider Name (Legal Business Name): KENNETH DALE SIMMONS III CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/28/2020
Last Update Date: 05/28/2020
Certification Date: 05/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

755 N 11TH ST STE P3600
BEAUMONT TX
77702-1515
US

IV. Provider business mailing address

3895 CYPRESS POINT DR
BEAUMONT TX
77707-5430
US

V. Phone/Fax

Practice location:
  • Phone: 409-838-5214
  • Fax:
Mailing address:
  • Phone: 409-673-6574
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number131500
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: