Provider Demographics
NPI:1578088985
Name:SIMMONS, TRACEY (FNP-BC)
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:
Last Name:SIMMONS
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6351 HWY 550
Mailing Address - Street 2:APT B
Mailing Address - City:CUBA
Mailing Address - State:NM
Mailing Address - Zip Code:87013
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6349 U.S. HIGHWAY 550
Practice Address - Street 2:
Practice Address - City:CUBA
Practice Address - State:NM
Practice Address - Zip Code:87013
Practice Address - Country:US
Practice Address - Phone:575-289-3291
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-07
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN0000022126363LF0000X
NM53377207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty