Provider Demographics
NPI:1124570858
Name:PHILLIPS, KEILANI
Entity Type:Individual
Prefix:
First Name:KEILANI
Middle Name:
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 1:1540 ALCAZAR STREET CHP-133
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90089-0080
Mailing Address - Country:US
Mailing Address - Phone:323-442-2850
Mailing Address - Fax:
Practice Address - Street 1:1540 ALCAZAR ST
Practice Address - Street 2:CHP-133
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90089-0080
Practice Address - Country:US
Practice Address - Phone:323-442-2850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-28
Last Update Date:2016-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program