Provider Demographics
NPI:1740217488
Name:SIMMONS, LORRAINE (CRNA)
Entity Type:Individual
Prefix:
First Name:LORRAINE
Middle Name:
Last Name:SIMMONS
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2171 W PARK CT
Mailing Address - Street 2:SUITE A
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30087-3555
Mailing Address - Country:US
Mailing Address - Phone:678-514-1991
Mailing Address - Fax:678-514-1993
Practice Address - Street 1:2701 N DECATUR RD
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033-5918
Practice Address - Country:US
Practice Address - Phone:404-501-5265
Practice Address - Fax:404-501-5266
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2007-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA033314367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAS27021Medicare UPIN
GA43ZCBCB25Medicare PIN