Provider Demographics
NPI:1467070557
Name:SIMMONS, RAQUEL (NP-C)
Entity Type:Individual
Prefix:
First Name:RAQUEL
Middle Name:
Last Name:SIMMONS
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:670 IVY BROOK WAY
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31210-5520
Mailing Address - Country:US
Mailing Address - Phone:478-737-8057
Mailing Address - Fax:
Practice Address - Street 1:670 IVY BROOK WAY
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31210-5520
Practice Address - Country:US
Practice Address - Phone:478-737-8057
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-06
Last Update Date:2020-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN170852363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily