=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740066273
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GRACE MAE SIMMONS FNP-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/31/2023
-----------------------------------------------------
Last Update Date | 08/31/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 34 SWAN ST
-----------------------------------------------------
City | BATAVIA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14020-3292
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 585-250-4567
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1473 EXCHANGE ST
-----------------------------------------------------
City | ALDEN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14004-1318
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 716-462-0718
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | F352695
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------