Provider Demographics
NPI:1538258520
Name:SIMMONS, THERESA L (CRNA)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:L
Last Name:SIMMONS
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 POLE CREEK CROSSING
Mailing Address - Street 2:
Mailing Address - City:SIDNEY
Mailing Address - State:NE
Mailing Address - Zip Code:69162-2900
Mailing Address - Country:US
Mailing Address - Phone:308-254-5825
Mailing Address - Fax:
Practice Address - Street 1:501 S BURMA AVE
Practice Address - Street 2:
Practice Address - City:GILLETTE
Practice Address - State:WY
Practice Address - Zip Code:82716-3426
Practice Address - Country:US
Practice Address - Phone:307-688-1524
Practice Address - Fax:307-687-7243
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2016-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE101379367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
9886Medicare ID - Type Unspecified