Provider Demographics
NPI:1467100875
Name:SIMMONS, MELISSA
Entity Type:Individual
Prefix:
First Name:MELISSA
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 1:401 E CHESTNUT ST UNIT 610
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-5711
Mailing Address - Country:US
Mailing Address - Phone:502-588-4450
Mailing Address - Fax:502-588-9539
Practice Address - Street 1:401 E CHESTNUT ST UNIT 610
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-5711
Practice Address - Country:US
Practice Address - Phone:502-588-4450
Practice Address - Fax:502-588-9539
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-15
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28173339C163W00000X
KY3018959363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse