Provider Demographics
NPI:1134473085
Name:SIMMONS, LACEY DAWN (LMP)
Entity Type:Individual
Prefix:
First Name:LACEY
Middle Name:DAWN
Last Name:SIMMONS
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1318 N STOUT RD
Mailing Address - Street 2:
Mailing Address - City:SPOKANE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:99206-4086
Mailing Address - Country:US
Mailing Address - Phone:509-572-0205
Mailing Address - Fax:
Practice Address - Street 1:3209 E 57TH AVE STE F
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99223-7040
Practice Address - Country:US
Practice Address - Phone:509-448-9398
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-30
Last Update Date:2012-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 00018110225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist