Provider Demographics
NPI:1053640649
Name:PHILLIPS, MANDI (NP-C)
Entity Type:Individual
Prefix:
First Name:MANDI
Middle Name:
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4900 S MONACO ST
Mailing Address - Street 2:#210
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80237-3486
Mailing Address - Country:US
Mailing Address - Phone:720-475-8750
Mailing Address - Fax:303-321-0367
Practice Address - Street 1:4500 E 9TH AVE
Practice Address - Street 2:#615
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80220-3912
Practice Address - Country:US
Practice Address - Phone:720-475-8750
Practice Address - Fax:303-321-0367
Is Sole Proprietor?:No
Enumeration Date:2009-12-10
Last Update Date:2022-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CONP-5980363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO47655020Medicaid
CO47655020Medicaid
COP01181425Medicare PIN