Provider Demographics
NPI:1164123816
Name:SIMMONS, JOHN ALEXANDER
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:ALEXANDER
Last Name:SIMMONS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:874 UNION AVE RM 325
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38103-3514
Mailing Address - Country:US
Mailing Address - Phone:901-448-6128
Mailing Address - Fax:
Practice Address - Street 1:874 UNION AVENUE RM 325
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38163-4046
Practice Address - Country:US
Practice Address - Phone:901-448-6128
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-10
Last Update Date:2024-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN229991163W00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No163W00000XNursing Service ProvidersRegistered Nurse