Provider Demographics
NPI:1093074635
Name:PHILLIPS, JULIA JAN
Entity Type:Individual
Prefix:
First Name:JULIA
Middle Name:JAN
Last Name:PHILLIPS
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 1:501 SW 75TH ST
Mailing Address - Street 2:UNIT E-6
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32607-1739
Mailing Address - Country:US
Mailing Address - Phone:352-682-9558
Mailing Address - Fax:
Practice Address - Street 1:5207 SW 91ST TER
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32608-7125
Practice Address - Country:US
Practice Address - Phone:352-335-5025
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-15
Last Update Date:2012-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA61280174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist