Provider Demographics
NPI:1558249953
Name:SIMMONS, TANISHA ANN
Entity type:Individual
Prefix:
First Name:TANISHA
Middle Name:ANN
Last Name:SIMMONS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:614 E CALLE CHULO RD
Mailing Address - Street 2:
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85338-1006
Mailing Address - Country:US
Mailing Address - Phone:219-290-6662
Mailing Address - Fax:
Practice Address - Street 1:614 E CALLE CHULO RD
Practice Address - Street 2:
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85338-1006
Practice Address - Country:US
Practice Address - Phone:219-290-6662
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-25
Last Update Date:2025-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ216195653747P1801X
IN21619565172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant