Provider Demographics
NPI:1710108758
Name:SIMMS, NIKKOL J (MSOTRL)
Entity Type:Individual
Prefix:
First Name:NIKKOL
Middle Name:J
Last Name:SIMMS
Suffix:
Gender:F
Credentials:MSOTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:516 SOUTH 3RD STREET
Mailing Address - Street 2:
Mailing Address - City:COLWYN
Mailing Address - State:PA
Mailing Address - Zip Code:19023-3113
Mailing Address - Country:US
Mailing Address - Phone:610-534-2919
Mailing Address - Fax:
Practice Address - Street 1:516 SOUTH 3RD STREET
Practice Address - Street 2:
Practice Address - City:COLWYN
Practice Address - State:PA
Practice Address - Zip Code:19023-3113
Practice Address - Country:US
Practice Address - Phone:610-534-2919
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOC008482171W00000X
NJ46TR00303100171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor