Healthcare Provider Details

I. General information

NPI: 1346731528
Provider Name (Legal Business Name): ELIZABETH JANE PHILLIPS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2018
Last Update Date: 05/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 W GAUTHIER RD
LAKE CHARLES LA
70605-7170
US

IV. Provider business mailing address

3561 E CABELLA DR
SULPHUR LA
70665-8762
US

V. Phone/Fax

Practice location:
  • Phone: 337-480-7056
  • Fax:
Mailing address:
  • Phone: 337-794-9112
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WN0002X
TaxonomyNeonatal Intensive Care Registered Nurse
License NumberAP06839
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: