Healthcare Provider Details

I. General information

NPI: 1295379196
Provider Name (Legal Business Name): MARY AMANDA SIMS RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/04/2019
Last Update Date: 11/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

229 EMPRESS ALEXANDRA PL
FREDERICKSBURG VA
22406-4092
US

IV. Provider business mailing address

229 EMPRESS ALEXANDRA PL
FREDERICKSBURG VA
22406-4092
US

V. Phone/Fax

Practice location:
  • Phone: 540-356-0567
  • Fax:
Mailing address:
  • Phone: 540-356-0567
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number0002076034
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: