Provider Demographics
NPI:1780997833
Name:SIMMONS, LAURA JANE (CRNA)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:JANE
Last Name:SIMMONS
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:JANE
Other - Last Name:BURT UNDERWOOD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CRNA
Mailing Address - Street 1:260 LAKEMONT DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30215-2344
Mailing Address - Country:US
Mailing Address - Phone:770-363-1274
Mailing Address - Fax:770-716-1580
Practice Address - Street 1:260 LAKEMONT DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30215-2344
Practice Address - Country:US
Practice Address - Phone:770-363-1274
Practice Address - Fax:770-716-1580
Is Sole Proprietor?:No
Enumeration Date:2010-07-19
Last Update Date:2013-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN149745367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA280727326AMedicaid