Provider Demographics
NPI:1033769260
Name:PHILLIPS, ELIZABETH ROSE (PMHNP-BC)
Entity Type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:ROSE
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2215 LILY LN
Mailing Address - Street 2:
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93455-1370
Mailing Address - Country:US
Mailing Address - Phone:228-213-7394
Mailing Address - Fax:
Practice Address - Street 1:338 S DAKOTA AVE
Practice Address - Street 2:
Practice Address - City:VANDENBERG AFB
Practice Address - State:CA
Practice Address - Zip Code:93437-6307
Practice Address - Country:US
Practice Address - Phone:805-606-2273
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-19
Last Update Date:2021-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WAN361190153363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program