Healthcare Provider Details

I. General information

NPI: 1578128443
Provider Name (Legal Business Name): SIQIN LUO SIMMONS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2019
Last Update Date: 10/01/2026
Certification Date: 10/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5770 S 1500 W
SALT LAKE CITY UT
84123-5216
US

IV. Provider business mailing address

PO BOX 27128
SALT LAKE CITY UT
84127-0128
US

V. Phone/Fax

Practice location:
  • Phone: 801-265-3412
  • Fax:
Mailing address:
  • Phone: 801-369-8989
  • Fax: 801-704-9741

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number8698377-4405
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code364SP0808X
TaxonomyPsychiatric/Mental Health Clinical Nurse Specialist
License Number8698377-4405
License Number StateUT
# 3
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: