MEDICARE: MRS. THERESA C PHILLIPS MSN APRN, BC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LC1500X	Community Health Nurse Practitioner	088676	MO

General Provider Information

NPI Number	:	1407952062
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. THERESA C PHILLIPS MSN APRN, BC

Provider Business Mailing Address
First Line	:	411 RIVERVIEW DR
Second Line	:
City	:	JEFFERSON CITY
State	:	MO
Zip	:	65101-4370
Country	:	US
Telephone Number	:	573-659-6692
Fax Number	:	573-635-7534

Provider Business Practice Location Address
First Line	:	1616 INDUSTRIAL DR
Second Line	:	COLE COUNTY HEALTH DEPARTMENT
City	:	JEFFERSON CITY
State	:	MO
Zip	:	65109-1471
Country	:	US
Telephone Number	:	573-636-2181
Fax Number	:	573-635-7534

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/14/2006
Last Update Date	:	07/08/2007

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