Healthcare Provider Details

I. General information

NPI: 1821815887
Provider Name (Legal Business Name): KATERI PHILLIPS RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/23/2024
Last Update Date: 09/23/2024
Certification Date: 09/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

409 DYKEN POND RD
PETERSBURG NY
12138-1909
US

IV. Provider business mailing address

442 DYKEN POND RD
PETERSBURG NY
12138-1801
US

V. Phone/Fax

Practice location:
  • Phone: 518-577-3881
  • Fax:
Mailing address:
  • Phone: 518-577-3881
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number754463-01
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN2340754
License Number StateMA
# 3
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number026.0111938
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: