Healthcare Provider Details

I. General information

NPI: 1770128126
Provider Name (Legal Business Name): MRS. JOANNA MCKNIGHT PHILLIPS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/08/2019
Last Update Date: 11/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8815 COLUMBIA 100 PKWY
COLUMBIA MD
21045-2361
US

IV. Provider business mailing address

12410 CLEARWATER WAY
UPPER MARLBORO MD
20772-6613
US

V. Phone/Fax

Practice location:
  • Phone: 877-776-5802
  • Fax:
Mailing address:
  • Phone: 843-476-1706
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: