Provider Demographics
NPI:1649369422
Name:MANLOVE-SIMMONS, KRIS ALLLISON (MD)
Entity type:Individual
Prefix:
First Name:KRIS
Middle Name:ALLLISON
Last Name:MANLOVE-SIMMONS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4554 SHUMART DR
Mailing Address - Street 2:
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30039-8547
Mailing Address - Country:US
Mailing Address - Phone:770-736-3069
Mailing Address - Fax:770-981-6302
Practice Address - Street 1:4367 NEW SNAPFINGER WOODS DR
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30035-2920
Practice Address - Country:US
Practice Address - Phone:770-981-2008
Practice Address - Fax:770-981-6302
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2011-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA057748207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA057748OtherLICENSE
GA057748OtherLICENSE
GAI52097Medicare UPIN