MEDICARE: SUSAN LYNNE SIMMONS RN, LMT

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	163WM1400X	Nurse Massage Therapist (NMT)	1189282 RN 27486 MA	FL

General Provider Information

NPI Number	:	1669655544
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUSAN LYNNE SIMMONS RN, LMT

Provider Business Mailing Address
First Line	:	3206 DR MARTIN LUTHER KING JR ST N
Second Line	:
City	:	ST PETERSBURG
State	:	FL
Zip	:	33704-1202
Country	:	US
Telephone Number	:	727-822-8400
Fax Number	:	727-822-8400

Provider Business Practice Location Address
First Line	:	3206 DR MARTIN LUTHER KING JR ST N
Second Line	:
City	:	ST PETERSBURG
State	:	FL
Zip	:	33704-1202
Country	:	US
Telephone Number	:	727-822-8400
Fax Number	:	727-822-8400

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

Provider Enumeration Date	:	12/13/2007
Last Update Date	:	12/13/2007

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