Provider Demographics
NPI:1427078245
Name:SIMON, FAITH SUSAN (FNP)
Entity type:Individual
Prefix:MS
First Name:FAITH
Middle Name:SUSAN
Last Name:SIMON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 38
Mailing Address - Street 2:
Mailing Address - City:MENDOCINO
Mailing Address - State:CA
Mailing Address - Zip Code:95460
Mailing Address - Country:US
Mailing Address - Phone:707-937-1055
Mailing Address - Fax:707-937-1061
Practice Address - Street 1:45081 LITTLE LAKE STREET
Practice Address - Street 2:
Practice Address - City:MENDOCINO
Practice Address - State:CA
Practice Address - Zip Code:95460
Practice Address - Country:US
Practice Address - Phone:707-937-1055
Practice Address - Fax:707-937-1061
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2012-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10815363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP00872334OtherRAILROAD MEDICARE
CARN422135OtherLICENSE NUMBER
CA1427078245Medicaid
CANPF10815OtherLICENSE NUMBER
CACL748YMedicare PIN