Provider Demographics
NPI:1295869246
Name:SIMMONS, SHONTA (ITFS BS CBRS PROF)
Entity type:Individual
Prefix:MRS
First Name:SHONTA
Middle Name:
Last Name:SIMMONS
Suffix:
Gender:F
Credentials:ITFS BS CBRS PROF
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 S GEORGE ST
Mailing Address - Street 2:
Mailing Address - City:GOLDSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27530-5715
Mailing Address - Country:US
Mailing Address - Phone:919-330-4802
Mailing Address - Fax:919-751-2320
Practice Address - Street 1:611 S GEORGE ST
Practice Address - Street 2:
Practice Address - City:GOLDSBORO
Practice Address - State:NC
Practice Address - Zip Code:27530-5715
Practice Address - Country:US
Practice Address - Phone:919-330-4802
Practice Address - Fax:919-751-2320
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2020-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8301201KMedicaid