Provider Demographics
NPI:1952795627
Name:SIMMONS, MELISA
Entity Type:Individual
Prefix:
First Name:MELISA
Middle Name:
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 1:2865 LOGAN AVENUE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92113-2411
Mailing Address - Country:US
Mailing Address - Phone:619-232-4357
Mailing Address - Fax:
Practice Address - Street 1:2865 LOGAN AVENUE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92113-2411
Practice Address - Country:US
Practice Address - Phone:619-232-4357
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-20
Last Update Date:2015-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program