Provider Demographics
NPI:1073691648
Name:SIMMONS, KATHLEEN (CO,LO)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:SIMMONS
Suffix:
Gender:F
Credentials:CO,LO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6315 E. BROAD ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43213
Mailing Address - Country:US
Mailing Address - Phone:614-863-6900
Mailing Address - Fax:614-863-8787
Practice Address - Street 1:6315 E BROAD ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43213-1506
Practice Address - Country:US
Practice Address - Phone:614-863-6900
Practice Address - Fax:614-863-8787
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0885065Medicaid