=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720562416
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CONNIE LOUANN PHILLIP FNP-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/19/2018
-----------------------------------------------------
Last Update Date | 08/04/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3575 MAYBANK HWY STE A
-----------------------------------------------------
City | JOHNS ISLAND
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29455-4871
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-402-1870
-----------------------------------------------------
Fax | 843-203-2241
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 751461
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28275-1461
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 888-472-0043
-----------------------------------------------------
Fax | 843-724-2440
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 22232
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------