Provider Demographics
NPI:1659775310
Name:SIMON, CHRISTINE ANN
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:ANN
Last Name:SIMON
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:CHRISTINE
Other - Middle Name:ANN
Other - Last Name:SIMON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPN
Mailing Address - Street 1:N4391 W COUNTY ROAD A
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:WI
Mailing Address - Zip Code:53073-4427
Mailing Address - Country:US
Mailing Address - Phone:920-980-5224
Mailing Address - Fax:
Practice Address - Street 1:N4391 W COUNTY ROAD A
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:WI
Practice Address - Zip Code:53073-4427
Practice Address - Country:US
Practice Address - Phone:920-980-5224
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-09
Last Update Date:2014-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI18301-31164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse