Provider Demographics
NPI:1790841914
Name:SIMON, DEBORAH H (NURSE)
Entity Type:Individual
Prefix:MRS
First Name:DEBORAH
Middle Name:H
Last Name:SIMON
Suffix:
Gender:F
Credentials:NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:RR 1 BOX 11A
Mailing Address - Street 2:
Mailing Address - City:PORTERVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39352-9702
Mailing Address - Country:US
Mailing Address - Phone:662-476-5826
Mailing Address - Fax:662-476-9871
Practice Address - Street 1:RR 1 BOX 11A
Practice Address - Street 2:
Practice Address - City:PORTERVILLE
Practice Address - State:MS
Practice Address - Zip Code:39352-9702
Practice Address - Country:US
Practice Address - Phone:662-476-5826
Practice Address - Fax:662-476-9871
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-29
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSP312059164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00770263Medicaid