Healthcare Provider Details

I. General information

NPI: 1710136718
Provider Name (Legal Business Name): STACEY LYNN PHILLIPS MSN, FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2008
Last Update Date: 10/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 WOODBRIDGE RD SUITE A
SOMERVILLE TN
38068-1242
US

IV. Provider business mailing address

25 WOODBRIDGE RD SUITE A
SOMERVILLE TN
38068-1242
US

V. Phone/Fax

Practice location:
  • Phone: 901-465-6353
  • Fax: 901-465-5948
Mailing address:
  • Phone: 901-465-6353
  • Fax: 901-465-5948

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number13658
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: