Provider Demographics
NPI:1992315238
Name:SIMON, EMILY MARIE (CNM)
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:MARIE
Last Name:SIMON
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:EMILY
Other - Middle Name:MARIE
Other - Last Name:MCCULLICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:208 PARKER ST
Mailing Address - Street 2:
Mailing Address - City:BOSCOBEL
Mailing Address - State:WI
Mailing Address - Zip Code:53805-1648
Mailing Address - Country:US
Mailing Address - Phone:608-375-2424
Mailing Address - Fax:
Practice Address - Street 1:208 PARKER ST
Practice Address - Street 2:
Practice Address - City:BOSCOBEL
Practice Address - State:WI
Practice Address - Zip Code:53805-1648
Practice Address - Country:US
Practice Address - Phone:608-375-2424
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-02
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5155363AM0700X
IL085009726363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical