Provider Demographics
NPI:1003459280
Name:SIMMONS, LAURA GRACE (MS, RDN, CD)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:GRACE
Last Name:SIMMONS
Suffix:
Gender:F
Credentials:MS, RDN, CD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2713 W PECAN RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85041-4421
Mailing Address - Country:US
Mailing Address - Phone:253-470-8399
Mailing Address - Fax:866-540-3225
Practice Address - Street 1:2713 W PECAN RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85041-4421
Practice Address - Country:US
Practice Address - Phone:253-470-8399
Practice Address - Fax:866-540-3225
Is Sole Proprietor?:No
Enumeration Date:2019-10-21
Last Update Date:2024-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019039025133V00000X
86119587133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA61078483OtherWA STATE DOH