Provider Demographics
NPI:1699286260
Name:SIMMONS, CARLA JAI
Entity type:Individual
Prefix:
First Name:CARLA
Middle Name:JAI
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 1:1300 BRAGG BLVD STE 1318
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28301-4296
Mailing Address - Country:US
Mailing Address - Phone:910-824-2339
Mailing Address - Fax:
Practice Address - Street 1:1300 BRAGG BLVD STE 1318
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28301-4296
Practice Address - Country:US
Practice Address - Phone:910-824-2339
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-23
Last Update Date:2017-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC85570174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty