MEDICARE: CARLISA JANE PHILLIPS APRN-CNP

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	363LP0200X	Pediatric Nurse Practitioner	64636	OK

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1679872857
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CARLISA JANE PHILLIPS APRN-CNP

Provider Business Mailing Address
First Line	:	5840 S MEMORIAL DR STE 301
Second Line	:
City	:	TULSA
State	:	OK
Zip	:	74145-9082
Country	:	US
Telephone Number	:	918-699-4250
Fax Number	:	918-921-8824

Provider Business Practice Location Address
First Line	:	5840 S MEMORIAL DR STE 301
Second Line	:
City	:	TULSA
State	:	OK
Zip	:	74145-9082
Country	:	US
Telephone Number	:	918-699-4250
Fax Number	:	918-921-8824

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

Provider Enumeration Date	:	03/27/2011
Last Update Date	:	09/16/2022

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