Provider Demographics
NPI:1912345372
Name:SIMMONS, TANDRA LAMIKIA
Entity Type:Individual
Prefix:MISS
First Name:TANDRA
Middle Name:LAMIKIA
Last Name:SIMMONS
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:PO BOX 358774
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32635-8774
Mailing Address - Country:US
Mailing Address - Phone:352-258-3450
Mailing Address - Fax:352-373-7818
Practice Address - Street 1:901 NW 8TH AVE STE A2
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32601-5000
Practice Address - Country:US
Practice Address - Phone:352-258-3450
Practice Address - Fax:352-379-5502
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-07
Last Update Date:2022-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL689678296251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL80-0388997Medicaid
FL689678296Medicaid