Provider Demographics
NPI:1265820625
Name:SIMMONS, SANDREA
Entity Type:Individual
Prefix:
First Name:SANDREA
Middle Name:
Last Name:SIMMONS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13937 BRADY
Mailing Address - Street 2:
Mailing Address - City:REDFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48239-2820
Mailing Address - Country:US
Mailing Address - Phone:313-915-8544
Mailing Address - Fax:313-472-5495
Practice Address - Street 1:13937 BRADY
Practice Address - Street 2:
Practice Address - City:REDFORD
Practice Address - State:MI
Practice Address - Zip Code:48239-2820
Practice Address - Country:US
Practice Address - Phone:313-915-8544
Practice Address - Fax:313-472-5495
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-07
Last Update Date:2015-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703110047164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse