Healthcare Provider Details

I. General information

NPI: 1821916008
Provider Name (Legal Business Name): KINYETTA PHILLIPS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/07/2026
Last Update Date: 07/07/2026
Certification Date: 07/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7095 TULANE RD N APT 102
HORN LAKE MS
38637-1574
US

IV. Provider business mailing address

PO BOX 676
SOUTHAVEN MS
38671-0007
US

V. Phone/Fax

Practice location:
  • Phone: 901-614-7583
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number10090813
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: