Provider Demographics
NPI:1023367612
Name:JOHNNIE MAE SIMMONS
Entity Type:Organization
Organization Name:JOHNNIE MAE SIMMONS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTER NURSING
Authorized Official - Prefix:MS
Authorized Official - First Name:JOHNNIE MAE
Authorized Official - Middle Name:
Authorized Official - Last Name:SIMMONS
Authorized Official - Suffix:
Authorized Official - Credentials:REGISTERED NURSING
Authorized Official - Phone:414-510-4893
Mailing Address - Street 1:4560 N. 40TH ST,
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53209
Mailing Address - Country:US
Mailing Address - Phone:414-510-4893
Mailing Address - Fax:
Practice Address - Street 1:4560 N. 40TH ST,
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53209
Practice Address - Country:US
Practice Address - Phone:414-510-4893
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-29
Last Update Date:2012-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1674523140N1450X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3140N1450XNursing & Custodial Care FacilitiesSkilled Nursing FacilityNursing Care, Pediatric