Provider Demographics
NPI:1902502008
Name:SIMMONS, KHADENE
Entity Type:Individual
Prefix:
First Name:KHADENE
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 1:7503 TANGLE RUSH DR
Mailing Address - Street 2:
Mailing Address - City:GIBSONTON
Mailing Address - State:FL
Mailing Address - Zip Code:33534-5310
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2985 DREW ST
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33759-3012
Practice Address - Country:US
Practice Address - Phone:813-302-8400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-01
Last Update Date:2023-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11023908363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health