Provider Demographics
NPI:1609546852
Name:SIMMONS, SHAMEKA SHANTL
Entity Type:Individual
Prefix:
First Name:SHAMEKA
Middle Name:SHANTL
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 1:3267 SNOWY EGRET DR
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70615-5364
Mailing Address - Country:US
Mailing Address - Phone:337-853-0474
Mailing Address - Fax:
Practice Address - Street 1:3267 SNOWY EGRET DR
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70615-5364
Practice Address - Country:US
Practice Address - Phone:337-853-0474
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-19
Last Update Date:2021-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA006584019172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver