Provider Demographics
NPI:1649534876
Name:SIMON, SAMMARA ARRYN
Entity type:Individual
Prefix:
First Name:SAMMARA
Middle Name:ARRYN
Last Name:SIMON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1706 COURT NORTH DR
Mailing Address - Street 2:
Mailing Address - City:MELVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11747-8143
Mailing Address - Country:US
Mailing Address - Phone:631-393-2994
Mailing Address - Fax:
Practice Address - Street 1:1706 COURT NORTH DR
Practice Address - Street 2:
Practice Address - City:MELVILLE
Practice Address - State:NY
Practice Address - Zip Code:11747-8143
Practice Address - Country:US
Practice Address - Phone:631-393-2994
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-03
Last Update Date:2012-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1644551174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist