Basic Information
| Provider Information | |||||||||
| NPI: | 1417359159 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SIMMONS | ||||||||
| FirstName: | ANNETTE | ||||||||
| MiddleName: | SUSAN | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | I | ||||||||
| Credential: | MFTI | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2077 | ||||||||
| Address2: | |||||||||
| City: | UKIAH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954822077 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7074672010 | ||||||||
| FaxNumber: | 7074626994 | ||||||||
| Practice Location | |||||||||
| Address1: | 780 S DORA ST | ||||||||
| Address2: | |||||||||
| City: | UKIAH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954825348 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7074679065 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/25/2014 | ||||||||
| LastUpdateDate: | 11/12/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/12/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 305S00000X | IMF78196 | CA | Y | Managed Care Organizations | Point of Service |
ID Information
| ID | Type | State | Issuer | Description | NPI 1417359159 | 01 | CA | MEDICAL | OTHER |