Provider Demographics
NPI:1366822231
Name:SIMEON, WILLINE
Entity Type:Individual
Prefix:
First Name:WILLINE
Middle Name:
Last Name:SIMEON
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 1:10650 W STATE ROAD 84 STE 206
Mailing Address - Street 2:
Mailing Address - City:DAVIE
Mailing Address - State:FL
Mailing Address - Zip Code:33324-4235
Mailing Address - Country:US
Mailing Address - Phone:954-634-3636
Mailing Address - Fax:
Practice Address - Street 1:10650 W STATE ROAD 84 STE 206
Practice Address - Street 2:
Practice Address - City:DAVIE
Practice Address - State:FL
Practice Address - Zip Code:33324-4235
Practice Address - Country:US
Practice Address - Phone:954-634-3636
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-04
Last Update Date:2015-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL014884200Medicaid