Provider Demographics
NPI:1073871596
Name:NUGENT, PHYLLIS (RN)
Entity Type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:
Last Name:NUGENT
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13687 N LAKEVIEW DR
Mailing Address - Street 2:
Mailing Address - City:LEWISTOWN
Mailing Address - State:IL
Mailing Address - Zip Code:61542-9258
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13687 N LAKEVIEW DR
Practice Address - Street 2:
Practice Address - City:LEWISTOWN
Practice Address - State:IL
Practice Address - Zip Code:61542-9258
Practice Address - Country:US
Practice Address - Phone:309-547-2779
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-03
Last Update Date:2012-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041.393497163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse