Healthcare Provider Details

I. General information

NPI: 1033028816
Provider Name (Legal Business Name): KHADIJAH FIFE PHILLIPS NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/05/2026
Last Update Date: 09/05/2026
Certification Date: 08/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PO BOX 441065
KENNESAW GA
30160-9520
US

IV. Provider business mailing address

PO BOX 441065
KENNESAW GA
30160-9520
US

V. Phone/Fax

Practice location:
  • Phone: 516-782-8988
  • Fax:
Mailing address:
  • Phone: 516-782-8988
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberNP337283
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: