Provider Demographics
NPI:1447925938
Name:SIMMONS, LISA E
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:E
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 1:2819 FOREST GROVE AVE
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45406-4038
Mailing Address - Country:US
Mailing Address - Phone:937-305-5108
Mailing Address - Fax:
Practice Address - Street 1:1 ELIZABETH PL
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45417-3445
Practice Address - Country:US
Practice Address - Phone:937-609-8627
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-16
Last Update Date:2021-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0002573175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist