Basic Information
| Provider Information | |||||||||
| NPI: | 1720155716 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SIMMONS | ||||||||
| FirstName: | AMY | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | RD | ||||||||
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| Mailing Information | |||||||||
| Address1: | N171W20510 NORTHVIEW DR | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530379442 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2626772108 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1640 E SUMNER ST | ||||||||
| Address2: | |||||||||
| City: | HARTFORD | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530272684 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2626704000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/29/2006 | ||||||||
| LastUpdateDate: | 07/18/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 967 | WI | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.