Provider Demographics
NPI:1639358716
Name:SIMMONS-ELLINGTON, WYLENE B (LICENSED MIDWIFE)
Entity Type:Individual
Prefix:MRS
First Name:WYLENE
Middle Name:B
Last Name:SIMMONS-ELLINGTON
Suffix:
Gender:F
Credentials:LICENSED MIDWIFE
Other - Prefix:MRS
Other - First Name:WYLENE
Other - Middle Name:B
Other - Last Name:SIMMONS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LICENSED MIDWIFE
Mailing Address - Street 1:2331 N STATE ROAD 7 STE 124
Mailing Address - Street 2:
Mailing Address - City:LAUDERDALE LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:33313-3771
Mailing Address - Country:US
Mailing Address - Phone:954-484-7698
Mailing Address - Fax:
Practice Address - Street 1:2331 N STATE ROAD 7 STE 124
Practice Address - Street 2:
Practice Address - City:LAUDERDALE LAKES
Practice Address - State:FL
Practice Address - Zip Code:33313-3771
Practice Address - Country:US
Practice Address - Phone:954-484-7698
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-25
Last Update Date:2007-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMW122175M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175M00000XOther Service ProvidersMidwife, Lay
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY4971OtherBLUE CROSS BLUE SHEILD
FL340135900Medicaid