Provider Demographics
NPI:1487171187
Name:RUSH, SIMONE (MED, ACT, LAT)
Entity type:Individual
Prefix:
First Name:SIMONE
Middle Name:
Last Name:RUSH
Suffix:
Gender:F
Credentials:MED, ACT, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3800 HARRISBURG RD APT 604
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72404-9188
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:217 OLYMPIC DRIVE
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401
Practice Address - Country:US
Practice Address - Phone:870-972-3923
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-24
Last Update Date:2017-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer