Provider Demographics
NPI:1134317241
Name:SIMMONS, LANA KELLY (FNP-BC)
Entity Type:Individual
Prefix:
First Name:LANA
Middle Name:KELLY
Last Name:SIMMONS
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:910-454-4032
Mailing Address - Fax:704-454-4033
Practice Address - Street 1:2950 PINE PLANTATION PKWY
Practice Address - Street 2:
Practice Address - City:OAK ISLAND
Practice Address - State:NC
Practice Address - Zip Code:28461-0119
Practice Address - Country:US
Practice Address - Phone:910-454-4032
Practice Address - Fax:910-454-4033
Is Sole Proprietor?:No
Enumeration Date:2007-10-15
Last Update Date:2019-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5003739363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2593115Medicare PIN