Provider Demographics
NPI:1134742885
Name:SIMMONS, KENNETH DALE III (CRNA)
Entity type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:DALE
Last Name:SIMMONS
Suffix:III
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
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Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:3895 CYPRESS POINT DR
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77707-5430
Mailing Address - Country:US
Mailing Address - Phone:409-673-6574
Mailing Address - Fax:
Practice Address - Street 1:755 N 11TH ST STE P3600
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77702-1515
Practice Address - Country:US
Practice Address - Phone:409-838-5214
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-28
Last Update Date:2020-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL131500367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered