Healthcare Provider Details

I. General information

NPI: 1306337332
Provider Name (Legal Business Name): PHYLLIS EVON SOLOMON FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: PHYLISS EVON SOLOMON FNP

II. Dates (important events)

Enumeration Date: 05/25/2018
Last Update Date: 07/27/2023
Certification Date: 07/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1570 BRAMPTON AVE
STATESBORO GA
30458-0855
US

IV. Provider business mailing address

1570 BRAMPTON AVE
STATESBORO GA
30458-0855
US

V. Phone/Fax

Practice location:
  • Phone: 912-764-9196
  • Fax:
Mailing address:
  • Phone: 912-764-9196
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License NumberRN150971
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN150971
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: