Healthcare Provider Details

I. General information

NPI: 1487684981
Provider Name (Legal Business Name): MARY CAROL PHILLIPS CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/03/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 RIDGE AVE
WASHINGTON PA
15301-3449
US

IV. Provider business mailing address

180 1/2 HIGHVIEW DR
UPPER ST CLAIR PA
15241-1637
US

V. Phone/Fax

Practice location:
  • Phone: 724-250-7790
  • Fax: 724-250-7568
Mailing address:
  • Phone: 412-833-9808
  • Fax: 724-250-7568

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberTP003855B
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: