Provider Demographics
NPI:1710006481
Name:HUTSON SIMONE, NICOLE R (APRN, CPNP)
Entity Type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:R
Last Name:HUTSON SIMONE
Suffix:
Gender:F
Credentials:APRN, CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 RAWLS DR STE 100
Mailing Address - Street 2:
Mailing Address - City:MCCOMB
Mailing Address - State:MS
Mailing Address - Zip Code:39648-2852
Mailing Address - Country:US
Mailing Address - Phone:601-684-7623
Mailing Address - Fax:877-795-9891
Practice Address - Street 1:300 RAWLS DR STE 100
Practice Address - Street 2:
Practice Address - City:MCCOMB
Practice Address - State:MS
Practice Address - Zip Code:39648-2852
Practice Address - Country:US
Practice Address - Phone:601-684-7623
Practice Address - Fax:877-795-9891
Is Sole Proprietor?:No
Enumeration Date:2007-03-27
Last Update Date:2017-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP04664363LP0200X
MSR887980363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS06179048Medicaid
LA1722961Medicaid