Healthcare Provider Details

I. General information

NPI: 1104163021
Provider Name (Legal Business Name): PHYLLIS JEAN JUSTUS APRN, FNP, MSN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2013
Last Update Date: 04/04/2022
Certification Date: 04/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 VALLEY ST NE
ABINGDON VA
24210-2912
US

IV. Provider business mailing address

1327 HORSEPOWER RD
GRUNDY VA
24614-7439
US

V. Phone/Fax

Practice location:
  • Phone: 276-206-8197
  • Fax: 276-206-8716
Mailing address:
  • Phone: 276-202-1546
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024170560
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: