Provider Demographics
NPI:1518326446
Name:SIMMONDS, KHADIJAH LATISSE THERESA (CNA)
Entity Type:Individual
Prefix:
First Name:KHADIJAH
Middle Name:LATISSE THERESA
Last Name:SIMMONDS
Suffix:
Gender:F
Credentials:CNA
Other - Prefix:
Other - First Name:KHADIJAH
Other - Middle Name:LATISSE THERESA
Other - Last Name:SIMMONDS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNA
Mailing Address - Street 1:159 JOHNSTON ST
Mailing Address - Street 2:
Mailing Address - City:NEWBURGH
Mailing Address - State:NY
Mailing Address - Zip Code:12550-4523
Mailing Address - Country:US
Mailing Address - Phone:845-219-8402
Mailing Address - Fax:
Practice Address - Street 1:159 JOHNSTON ST
Practice Address - Street 2:
Practice Address - City:NEWBURGH
Practice Address - State:NY
Practice Address - Zip Code:12550-4523
Practice Address - Country:US
Practice Address - Phone:845-219-8402
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-20
Last Update Date:2016-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY343272180612E376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide