Provider Demographics
NPI:1558729400
Name:SIMONOVA, ELENA
Entity Type:Individual
Prefix:
First Name:ELENA
Middle Name:
Last Name:SIMONOVA
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 1:2814 GRANDE PKWY APT 106
Mailing Address - Street 2:
Mailing Address - City:PALM BEACH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33410-2918
Mailing Address - Country:US
Mailing Address - Phone:561-537-0399
Mailing Address - Fax:
Practice Address - Street 1:2814 GRANDE PKWY APT 106
Practice Address - Street 2:
Practice Address - City:PALM BEACH GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33410-2918
Practice Address - Country:US
Practice Address - Phone:561-537-0399
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-07
Last Update Date:2016-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL3692171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist