Healthcare Provider Details

I. General information

NPI: 1588339527
Provider Name (Legal Business Name): PHYLLIS E PHILLIPS NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/11/2021
Last Update Date: 11/10/2023
Certification Date: 11/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

814 JEFFERSON AVE
MEMPHIS TN
38105-5041
US

IV. Provider business mailing address

814 JEFFERSON AVE
MEMPHIS TN
38105-5041
US

V. Phone/Fax

Practice location:
  • Phone: 901-222-9428
  • Fax:
Mailing address:
  • Phone: 901-222-9428
  • Fax: 901-222-9337

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number30030
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: