Provider Demographics
NPI:1730511486
Name:SIMONSSON, HENRIETTA A (RN)
Entity type:Individual
Prefix:
First Name:HENRIETTA
Middle Name:A
Last Name:SIMONSSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6801 THIRD GATE RD
Mailing Address - Street 2:
Mailing Address - City:WILLITS
Mailing Address - State:CA
Mailing Address - Zip Code:95490-9566
Mailing Address - Country:US
Mailing Address - Phone:707-459-9488
Mailing Address - Fax:
Practice Address - Street 1:1 MADRONE ST
Practice Address - Street 2:
Practice Address - City:WILLITS
Practice Address - State:CA
Practice Address - Zip Code:95490-4225
Practice Address - Country:US
Practice Address - Phone:707-456-3050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-05
Last Update Date:2013-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARN 418370163WD0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WD0400XNursing Service ProvidersRegistered NurseDiabetes Educator