Provider Demographics
NPI:1669712840
Name:STEWART SIMMONS, TERRIKA DENE (AGNP-C)
Entity type:Individual
Prefix:MS
First Name:TERRIKA
Middle Name:DENE
Last Name:STEWART SIMMONS
Suffix:
Gender:F
Credentials:AGNP-C
Other - Prefix:MS
Other - First Name:TERRIKA
Other - Middle Name:DENE
Other - Last Name:STEWART SIMMONS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:AGNP-C
Mailing Address - Street 1:PO BOX 602658
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-2658
Mailing Address - Country:US
Mailing Address - Phone:336-716-2011
Mailing Address - Fax:
Practice Address - Street 1:4614 COUNTRY CLUB RD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27104-3520
Practice Address - Country:US
Practice Address - Phone:336-716-6099
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-25
Last Update Date:2016-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC156756363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC453142512Medicare UPIN