Provider Demographics
NPI:1154094902
Name:PHILLIPS, MARY
Entity Type:Individual
Prefix:
First Name:MARY
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 1:20100 SHIRE OAK DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23803-1417
Mailing Address - Country:US
Mailing Address - Phone:804-590-9246
Mailing Address - Fax:
Practice Address - Street 1:20100 SHIRE OAK DR
Practice Address - Street 2:
Practice Address - City:SOUTH CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23803-1417
Practice Address - Country:US
Practice Address - Phone:804-590-9246
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-28
Last Update Date:2021-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA3747A0650X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider