Provider Demographics
NPI:1306053509
Name:SIMMONS, CYNTAVIA E (LMP)
Entity type:Individual
Prefix:MS
First Name:CYNTAVIA
Middle Name:E
Last Name:SIMMONS
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1615 196TH STREET CT E
Mailing Address - Street 2:
Mailing Address - City:SPANAWAY
Mailing Address - State:WA
Mailing Address - Zip Code:98387-8085
Mailing Address - Country:US
Mailing Address - Phone:253-380-5194
Mailing Address - Fax:253-566-3164
Practice Address - Street 1:2603 BRIDGEPORT WAY W
Practice Address - Street 2:SUITE A
Practice Address - City:UNIVERSITY PLACE
Practice Address - State:WA
Practice Address - Zip Code:98466-4724
Practice Address - Country:US
Practice Address - Phone:253-566-1232
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00020617174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist