Provider Demographics
NPI:1306443916
Name:VARGHESE, SIMMY REGIN
Entity type:Individual
Prefix:
First Name:SIMMY
Middle Name:REGIN
Last Name:VARGHESE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SIMMY
Other - Middle Name:
Other - Last Name:GEORGE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1613 HAMMOCK GROVE LN
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32225-5575
Mailing Address - Country:US
Mailing Address - Phone:904-616-7010
Mailing Address - Fax:
Practice Address - Street 1:1613 HAMMOCK GROVE LN
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32225-5575
Practice Address - Country:US
Practice Address - Phone:904-616-7010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-06
Last Update Date:2020-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11008910363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care