Healthcare Provider Details

I. General information

NPI: 1780211300
Provider Name (Legal Business Name): AMANDA RENEE PHILLIPS NP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2020
Last Update Date: 07/11/2024
Certification Date: 07/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4200 REGENT ST STE 200
COLUMBUS OH
43219-6229
US

IV. Provider business mailing address

3034 HORTON AVE
SAN DIEGO CA
92103-6008
US

V. Phone/Fax

Practice location:
  • Phone: 877-870-1775
  • Fax: 614-968-8840
Mailing address:
  • Phone: 425-241-5977
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number95013542
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: