1902445679 NPI number — KATIE L PHILLIPS CNM

Table of content: KATIE L PHILLIPS CNM (NPI 1902445679)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902445679 NPI number — KATIE L PHILLIPS CNM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PHILLIPS
Provider First Name:
KATIE
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CNM
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1902445679
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/07/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4250 HOSPITAL DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MARIANNA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32446-1917
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-526-6711
Provider Business Mailing Address Fax Number:
850-526-5021

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1415 PORTLAND AVE STE 400
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROCHESTER
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14621-3022
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
585-922-4200
Provider Business Practice Location Address Fax Number:
585-922-4922
Provider Enumeration Date:
12/30/2019

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 367A00000X , with the licence number:  11005940 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 367A00000X , with the licence number: 590699 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)