Provider Demographics
NPI:1811535388
Name:SIMON, CRAIG (LPN)
Entity type:Individual
Prefix:
First Name:CRAIG
Middle Name:
Last Name:SIMON
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2243 PIKE DR
Mailing Address - Street 2:
Mailing Address - City:GREENBACKVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:23356-2670
Mailing Address - Country:US
Mailing Address - Phone:443-735-6705
Mailing Address - Fax:
Practice Address - Street 1:1532 OCEAN HWY STE 102
Practice Address - Street 2:
Practice Address - City:POCOMOKE CITY
Practice Address - State:MD
Practice Address - Zip Code:21851-3023
Practice Address - Country:US
Practice Address - Phone:443-437-7128
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-16
Last Update Date:2024-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0002076818164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse