Provider Demographics
NPI:1336186048
Name:SIMMONS, KELLI J (APRN)
Entity type:Individual
Prefix:
First Name:KELLI
Middle Name:J
Last Name:SIMMONS
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1570 EUSTIS ST
Mailing Address - Street 2:APARTMENT 133
Mailing Address - City:LAUDERDALE
Mailing Address - State:MN
Mailing Address - Zip Code:55108-1260
Mailing Address - Country:US
Mailing Address - Phone:651-646-0172
Mailing Address - Fax:
Practice Address - Street 1:420 DELAWARE STREET SOUTHEAST
Practice Address - Street 2:MAYO MAIL CODE 450
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55455
Practice Address - Country:US
Practice Address - Phone:612-626-5919
Practice Address - Fax:612-625-4406
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2010-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR183718-8364SA2200X
MO093545364SA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOP00104707OtherRR MEDICARE
MO427483300Medicaid
MO816675236Medicare PIN
MO041080010Medicare PIN
P95275Medicare UPIN
MO427483300Medicaid