Healthcare Provider Details

I. General information

NPI: 1689017915
Provider Name (Legal Business Name): DIANNA PHILLIPS RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DIANNA PHILLIPS RN

II. Dates (important events)

Enumeration Date: 04/17/2013
Last Update Date: 04/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1040 RIVER OAKS DR SUITE 302
JACKSON MS
39232-9530
US

IV. Provider business mailing address

1040 RIVER OAKS DR SUITE 302
JACKSON MS
39232-9530
US

V. Phone/Fax

Practice location:
  • Phone: 601-939-9723
  • Fax: 601-939-9924
Mailing address:
  • Phone: 601-939-9723
  • Fax: 601-939-9924

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR724777
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: