Healthcare Provider Details

I. General information

NPI: 1770705014
Provider Name (Legal Business Name): PHYLLIS RICKETTS PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14 CORTLAND SHIRE DR
MOORESTOWN NJ
08057-3944
US

IV. Provider business mailing address

14 CORTLAND SHIRE DR
MOORESTOWN NJ
08057-3944
US

V. Phone/Fax

Practice location:
  • Phone: 609-760-4094
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081H0002X
TaxonomyHospice and Palliative Medicine (Physical Medicine & Rehabilitation) Physician
License NumberPT005093L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: