Provider Demographics
NPI:1114922937
Name:FISHER, PHYLLIS C (FNP)
Entity Type:Individual
Prefix:MRS
First Name:PHYLLIS
Middle Name:C
Last Name:FISHER
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:MRS
Other - First Name:PHYLLIS
Other - Middle Name:C
Other - Last Name:DEEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 850
Mailing Address - Street 2:
Mailing Address - City:ROGERSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37857-0850
Mailing Address - Country:US
Mailing Address - Phone:423-743-6135
Mailing Address - Fax:423-743-0035
Practice Address - Street 1:1826 N MAIN AVE
Practice Address - Street 2:
Practice Address - City:ERWIN
Practice Address - State:TN
Practice Address - Zip Code:37650-8932
Practice Address - Country:US
Practice Address - Phone:423-743-6135
Practice Address - Fax:423-743-0035
Is Sole Proprietor?:No
Enumeration Date:2005-06-17
Last Update Date:2010-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN6698363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3343285Medicaid
TN3043701OtherBCBST
500004287Medicare UPIN
TNS27679Medicare UPIN
TN3343285Medicaid
33432851Medicare PIN
3703865Medicare PIN