Healthcare Provider Details

I. General information

NPI: 1760943385
Provider Name (Legal Business Name): STEPHANIE AUDRIANNA PHILLIPS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2019
Last Update Date: 10/10/2024
Certification Date: 10/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

819 N SHIAWASSEE ST STE 110
OWOSSO MI
48867-1601
US

IV. Provider business mailing address

819 N SHIAWASSEE ST STE 110
OWOSSO MI
48867-1601
US

V. Phone/Fax

Practice location:
  • Phone: 989-723-1390
  • Fax: 989-725-1415
Mailing address:
  • Phone: 989-723-1390
  • Fax: 989-725-1415

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License Number4301511940
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number4301511940
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: