MEDICARE: SHELBY SIMMONS NP

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	4704321560	MI

General Provider Information

NPI Number	:	1730812371
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHELBY SIMMONS NP

Provider Business Mailing Address
First Line	:	1407 E MICHIGAN AVE
Second Line	:
City	:	JACKSON
State	:	MI
Zip	:	49202-3517
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1407 E MICHIGAN AVE
Second Line	:
City	:	JACKSON
State	:	MI
Zip	:	49202-3517
Country	:	US
Telephone Number	:	517-888-6348
Fax Number	:

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

Provider Enumeration Date	:	07/01/2022
Last Update Date	:	07/01/2022

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