Healthcare Provider Details

I. General information

NPI: 1114597259
Provider Name (Legal Business Name): CORLISS Y PHILLIPS LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/30/2021
Last Update Date: 12/21/2025
Certification Date: 12/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1903 PLOVER AVE APT A
FORT PIERCE FL
34949-3446
US

IV. Provider business mailing address

1903 PLOVER AVE APT A
FORT PIERCE FL
34949-3446
US

V. Phone/Fax

Practice location:
  • Phone: 772-940-3736
  • Fax:
Mailing address:
  • Phone: 772-940-3736
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number234020
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code376J00000X
TaxonomyHomemaker
License Number234020
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number30212271
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number30212271
License Number StateFL
# 5
Primary TaxonomyY
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number234020
License Number StateFL
# 6
Primary TaxonomyN
Taxonomy Code376J00000X
TaxonomyHomemaker
License Number30212271
License Number StateFL
# 7
Primary TaxonomyN
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number5195534
License Number StateFL
# 8
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number30212271
License Number StateFL
# 9
Primary TaxonomyN
Taxonomy Code372500000X
TaxonomyChore Provider
License Number30212271
License Number StateFL
# 10
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number30212271
License Number StateFL
# 11
Primary TaxonomyN
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number30212271
License Number StateFL
# 12
Primary TaxonomyN
Taxonomy Code372500000X
TaxonomyChore Provider
License Number234020
License Number StateFL
# 13
Primary TaxonomyN
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License NumberPN5195534
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: