Provider Demographics
NPI:1790182293
Name:SIMON, REBECCA J
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:J
Last Name:SIMON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9861 ALPINE DR
Mailing Address - Street 2:
Mailing Address - City:KIRTLAND
Mailing Address - State:OH
Mailing Address - Zip Code:44094-8633
Mailing Address - Country:US
Mailing Address - Phone:440-269-9559
Mailing Address - Fax:
Practice Address - Street 1:9861 ALPINE DR
Practice Address - Street 2:
Practice Address - City:KIRTLAND
Practice Address - State:OH
Practice Address - Zip Code:44094-8633
Practice Address - Country:US
Practice Address - Phone:440-269-9559
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-26
Last Update Date:2014-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH108941164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse