Provider Demographics
NPI:1033773502
Name:FUSELIER-SHIELDS, PHILA P
Entity Type:Individual
Prefix:MRS
First Name:PHILA
Middle Name:P
Last Name:FUSELIER-SHIELDS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7709 E 66TH ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74133-1842
Mailing Address - Country:US
Mailing Address - Phone:918-948-3752
Mailing Address - Fax:
Practice Address - Street 1:4300 S HARVARD AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-2619
Practice Address - Country:US
Practice Address - Phone:918-728-2228
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-30
Last Update Date:2019-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
OK171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator