Provider Demographics
NPI:1366486920
Name:SIMONI, JENNIFER B (PA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:B
Last Name:SIMONI
Suffix:
Gender:F
Credentials:PA
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 64575
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28306-0575
Mailing Address - Country:US
Mailing Address - Phone:910-630-1112
Mailing Address - Fax:910-425-1110
Practice Address - Street 1:1540 PURDUE DR STE 200
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28303-5510
Practice Address - Country:US
Practice Address - Phone:910-630-1112
Practice Address - Fax:910-425-1110
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2021-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-00332363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2625033OtherUHC
NC2625033OtherUHC
P35942Medicare UPIN