Healthcare Provider Details

I. General information

NPI: 1598304958
Provider Name (Legal Business Name): SOPHIA A PHILLIP FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/03/2020
Last Update Date: 01/03/2020
Certification Date: 01/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

65 N MADISON AVE STE 800
PASADENA CA
91101-2038
US

IV. Provider business mailing address

65 N MADISON AVE STE 800
PASADENA CA
91101-2038
US

V. Phone/Fax

Practice location:
  • Phone: 626-792-3141
  • Fax:
Mailing address:
  • Phone: 626-792-3141
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95012382
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: