1538447537 NPI number — MISS WILMA MELLISSA SIMON MSBS

Table of content: MISS WILMA MELLISSA SIMON MSBS (NPI 1538447537)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538447537 NPI number — MISS WILMA MELLISSA SIMON MSBS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SIMON
Provider First Name:
WILMA
Provider Middle Name:
MELLISSA
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
MSBS
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1538447537
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/26/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
602 SW 38TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAWTON
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73505-6912
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
580-248-5780
Provider Business Mailing Address Fax Number:
580-353-6798

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
602 SW 38TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAWTON
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73505-6912
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
580-248-5780
Provider Business Practice Location Address Fax Number:
580-353-6798
Provider Enumeration Date:
07/26/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 171M00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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