Provider Demographics
NPI:1184066052
Name:SIMMONS, WANDA BETH (LAC)
Entity type:Individual
Prefix:
First Name:WANDA
Middle Name:BETH
Last Name:SIMMONS
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 REEF RD.
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06824
Mailing Address - Country:US
Mailing Address - Phone:860-916-3626
Mailing Address - Fax:
Practice Address - Street 1:20 REEF RD.
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CT
Practice Address - Zip Code:06824
Practice Address - Country:US
Practice Address - Phone:860-916-3626
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-22
Last Update Date:2013-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT426171100000X
HI935171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist