Healthcare Provider Details

I. General information

NPI: 1255899324
Provider Name (Legal Business Name): PATRICK RYAN PHILLIPS LPN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2019
Last Update Date: 03/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1215 FULTON ST E
GRAND RAPIDS MI
49503-3849
US

IV. Provider business mailing address

102 PERRINE PL NW
GRAND RAPIDS MI
49534-8719
US

V. Phone/Fax

Practice location:
  • Phone: 616-742-0351
  • Fax:
Mailing address:
  • Phone: 616-706-2155
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number4703120713
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: