Provider Demographics
NPI:1063021608
Name:SIMONELLI, ANTHONY MARINO
Entity Type:Individual
Prefix:MR
First Name:ANTHONY
Middle Name:MARINO
Last Name:SIMONELLI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:784 W HILE RD
Mailing Address - Street 2:
Mailing Address - City:NORTON SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:49441-5469
Mailing Address - Country:US
Mailing Address - Phone:231-343-7850
Mailing Address - Fax:
Practice Address - Street 1:1115 3RD ST
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49441-2170
Practice Address - Country:US
Practice Address - Phone:231-343-7850
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-29
Last Update Date:2020-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI174H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator