Provider Demographics
NPI:1619576212
Name:SIMON, ELIZABETH
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:SIMON
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 1:6901 SNIDER PLZ
Mailing Address - Street 2:STE 130
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75205-5649
Mailing Address - Country:US
Mailing Address - Phone:214-696-8803
Mailing Address - Fax:
Practice Address - Street 1:421 E STATE HIGHWAY 114
Practice Address - Street 2:
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-3635
Practice Address - Country:US
Practice Address - Phone:817-865-4400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-23
Last Update Date:2021-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX751284163W00000X
TX1021112363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
No163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty