Healthcare Provider Details

I. General information

NPI: 1003670290
Provider Name (Legal Business Name): AVIS MICHELLE PHILLIPS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AVIS MICHELLE PHILLIPS RN

II. Dates (important events)

Enumeration Date: 02/08/2024
Last Update Date: 02/08/2024
Certification Date: 02/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 E 38TH ST
MARION IN
46953-4568
US

IV. Provider business mailing address

3502 S MERIDIAN ST
MARION IN
46953-4406
US

V. Phone/Fax

Practice location:
  • Phone: 765-674-3321
  • Fax: 765-677-5167
Mailing address:
  • Phone: 765-243-9144
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP2201X
TaxonomyAmbulatory Care Registered Nurse
License Number28171079A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: