Provider Demographics
NPI:1578987764
Name:SIMMONS, AMANDA NICOLE
Entity Type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:NICOLE
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 1:7487 S STATE ROAD 121
Mailing Address - Street 2:
Mailing Address - City:MACCLENNY
Mailing Address - State:FL
Mailing Address - Zip Code:32063-5451
Mailing Address - Country:US
Mailing Address - Phone:904-259-6211
Mailing Address - Fax:
Practice Address - Street 1:7487 S STATE ROAD 121
Practice Address - Street 2:
Practice Address - City:MACCLENNY
Practice Address - State:FL
Practice Address - Zip Code:32063-5451
Practice Address - Country:US
Practice Address - Phone:904-259-6211
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-10
Last Update Date:2014-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY8741103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical