=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912571613
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHANCE PHILLIPS, FNP, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/17/2021
-----------------------------------------------------
Last Update Date | 05/17/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4564 S HARVARD AVE STE B
-----------------------------------------------------
City | TULSA
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74135-2918
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-508-2220
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2706 E 39TH PL
-----------------------------------------------------
City | TULSA
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74105-8209
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 806-886-0062
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/NURSE PRACTITIONER
-----------------------------------------------------
Name | CHANCE LEROY PHILLIPS
-----------------------------------------------------
Credential | APRN-CNP
-----------------------------------------------------
Telephone | 806-886-0062
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QH0100X
-----------------------------------------------------
Taxonomy Name | Health Service Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------