Healthcare Provider Details

I. General information

NPI: 1568907822
Provider Name (Legal Business Name): MARCIA ANGELLA PHILLIPS PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/22/2016
Last Update Date: 03/02/2022
Certification Date: 03/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 CORPORATE CENTER CT
STOCKBRIDGE GA
30281-6388
US

IV. Provider business mailing address

250 CORPORATE CENTER CT
STOCKBRIDGE GA
30281-6388
US

V. Phone/Fax

Practice location:
  • Phone: 770-954-8685
  • Fax: 770-389-3030
Mailing address:
  • Phone: 770-954-8685
  • Fax: 770-389-3030

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN195731
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberRN195731
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: