Healthcare Provider Details

I. General information

NPI: 1972731107
Provider Name (Legal Business Name): PHYLLIS MARIE EATON PHD, RN, PMHCNS-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2009
Last Update Date: 06/25/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 INDEPENDENCE CIR STE 3D
VIRGINIA BEACH VA
23455-6405
US

IV. Provider business mailing address

700 INDEPENDENCE CIR STE 3D
VIRGINIA BEACH VA
23455-6405
US

V. Phone/Fax

Practice location:
  • Phone: 757-473-8533
  • Fax: 757-456-0616
Mailing address:
  • Phone: 757-473-8533
  • Fax: 757-456-0616

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number0001128454
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code364SP0809X
TaxonomyAdult Psychiatric/Mental Health Clinical Nurse Specialist
License Number0015000876
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: