1073810628 NPI number — MS. KYLONI D PHILLIPS APN

Table of content: MS. KYLONI D PHILLIPS APN (NPI 1073810628)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073810628 NPI number — MS. KYLONI D PHILLIPS APN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PHILLIPS
Provider First Name:
KYLONI
Provider Middle Name:
D
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
APN
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:
1073810628
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/05/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1600 COIT RD
Provider Second Line Business Mailing Address:
SUITE # 104
Provider Business Mailing Address City Name:
PLANO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75075-6174
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
318-230-9020
Provider Business Mailing Address Fax Number:
972-519-1591

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1600 COIT RD
Provider Second Line Business Practice Location Address:
SUITE # 104
Provider Business Practice Location Address City Name:
PLANO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75075-6174
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-230-9020
Provider Business Practice Location Address Fax Number:
972-519-1591
Provider Enumeration Date:
02/17/2011

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: 363LA2100X , with the licence number:  788454 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 284967102 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 284967101 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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