MEDICARE: CHRISTINE ANN-AVERY SIMON RN

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	163W00000X	Registered Nurse	4704162158	MI

General Provider Information

NPI Number	:	1528312568
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHRISTINE ANN-AVERY SIMON RN

Provider Business Mailing Address
First Line	:	11615 HARTEL RD
Second Line	:	SUITE 108
City	:	GRAND LEDGE
State	:	MI
Zip	:	48837-9165
Country	:	US
Telephone Number	:	517-627-3281
Fax Number	:	517-627-8722

Provider Business Practice Location Address
First Line	:	11615 HARTEL RD
Second Line	:	SUITE 108
City	:	GRAND LEDGE
State	:	MI
Zip	:	48837-9165
Country	:	US
Telephone Number	:	517-627-3281
Fax Number	:	517-627-8722

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

Provider Enumeration Date	:	10/30/2012
Last Update Date	:	10/30/2012

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