Provider Demographics
NPI:1013329762
Name:SIMMONS, VIVIAN (PT)
Entity Type:Individual
Prefix:
First Name:VIVIAN
Middle Name:
Last Name:SIMMONS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4421 NW 39TH AVE
Mailing Address - Street 2:2-2
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32606
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4421 NW 39TH AVE
Practice Address - Street 2:2-2
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32606
Practice Address - Country:US
Practice Address - Phone:980-621-6912
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-29
Last Update Date:2019-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT29191225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
Y0MC6OtherFLORIDA BLUE
HU300ZMedicare PIN