Provider Demographics
NPI:1114597259
Name:PHILLIPS, CORLISS Y (LPN)
Entity Type:Individual
Prefix:
First Name:CORLISS
Middle Name:Y
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1903 PLOVER AVE APT A
Mailing Address - Street 2:
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34949-3446
Mailing Address - Country:US
Mailing Address - Phone:772-940-3736
Mailing Address - Fax:
Practice Address - Street 1:1903 PLOVER AVE APT A
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34949-3446
Practice Address - Country:US
Practice Address - Phone:772-940-3736
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-30
Last Update Date:2021-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL5195534164W00000X
FL234020376J00000X, 372600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes372600000XNursing Service Related ProvidersAdult CompanionGroup - Single Specialty
No164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Single Specialty
No376J00000XNursing Service Related ProvidersHomemaker
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0622Medicaid