=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023442050
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LEILANI GAIL SIMMONS LMT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/27/2013
-----------------------------------------------------
Last Update Date | 08/27/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1361 S SUMTER BLVD
-----------------------------------------------------
City | NORTH PORT
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34287-2339
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-423-2667
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7819 JAYMAN RD
-----------------------------------------------------
City | NORTH PORT
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34291-5778
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-276-5664
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | 47323
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------