Healthcare Provider Details

I. General information

NPI: 1598355448
Provider Name (Legal Business Name): MS. ANDREA MONIQUE PHELPS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/25/2021
Last Update Date: 01/25/2021
Certification Date: 01/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

221 OUTER BELLE RD APT A
DAYTON OH
45426-1538
US

IV. Provider business mailing address

221 OUTER BELLE RD APT A
DAYTON OH
45426-1538
US

V. Phone/Fax

Practice location:
  • Phone: 937-307-9639
  • Fax: 937-715-4049
Mailing address:
  • Phone: 937-626-4575
  • Fax: 937-715-4049

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246RP1900X
TaxonomyPhlebotomy Technician
License NumberF2L5L5E5
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: