Provider Demographics
NPI:1730812371
Name:SIMMONS, SHELBY (NP)
Entity type:Individual
Prefix:
First Name:SHELBY
Middle Name:
Last Name:SIMMONS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:SHELBY
Other - Middle Name:
Other - Last Name:TATAR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1407 E MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49202-3517
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1407 E MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49202-3517
Practice Address - Country:US
Practice Address - Phone:517-888-6348
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-01
Last Update Date:2022-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704321560363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily