1720562416 NPI number — CONNIE LOUANN PHILLIP FNP-C

Table of content: CONNIE LOUANN PHILLIP FNP-C (NPI 1720562416)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720562416 NPI number — CONNIE LOUANN PHILLIP FNP-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PHILLIP
Provider First Name:
CONNIE
Provider Middle Name:
LOUANN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
FNP-C
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:
1720562416
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/01/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 751461
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHARLOTTE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28275-1461
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
888-472-0043
Provider Business Mailing Address Fax Number:
843-724-2440

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4278 LADSON RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LADSON
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29456-5452
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-203-2240
Provider Business Practice Location Address Fax Number:
843-203-2241
Provider Enumeration Date:
09/19/2018

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: 363LF0000X , with the licence number:  22232 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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