MEDICARE: LISA MARIE SIMMS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	9383659	FL

General Provider Information

NPI Number	:	1366942708
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA MARIE SIMMS

Provider Business Mailing Address
First Line	:	3250 BROKEN BOW DR
Second Line	:
City	:	LAND O LAKES
State	:	FL
Zip	:	34639-9012
Country	:	US
Telephone Number	:	954-806-3079
Fax Number	:

Provider Business Practice Location Address
First Line	:	1011 N MACDILL AVE
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33607-5126
Country	:	US
Telephone Number	:	954-806-3079
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/12/2018
Last Update Date	:	02/12/2018

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