Healthcare Provider Details

I. General information

NPI: 1154676468
Provider Name (Legal Business Name): PHYLLIS JANE ENDICOTT CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2012
Last Update Date: 12/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 NAVARRE AVE
OREGON OH
43616-3207
US

IV. Provider business mailing address

5301 NEBRASKA AVE
TOLEDO OH
43615-4632
US

V. Phone/Fax

Practice location:
  • Phone: 419-696-7200
  • Fax: 419-696-7731
Mailing address:
  • Phone: 419-531-5544
  • Fax: 419-531-5117

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberNP-05219
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: