Provider Demographics
NPI:1265659247
Name:SIMMONS, KENYAWN JUDEA (FNP-C)
Entity Type:Individual
Prefix:
First Name:KENYAWN
Middle Name:JUDEA
Last Name:SIMMONS
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38489 CLEARBROOK DR
Mailing Address - Street 2:
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92563-5882
Mailing Address - Country:US
Mailing Address - Phone:707-694-0095
Mailing Address - Fax:
Practice Address - Street 1:2501 W BURBANK BLVD
Practice Address - Street 2:
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91505-2347
Practice Address - Country:US
Practice Address - Phone:818-856-9535
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-19
Last Update Date:2022-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95021826363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2723673Medicaid