Provider Demographics
NPI:1164042982
Name:PHYLLIS COULTER EVERETT
Entity Type:Organization
Organization Name:PHYLLIS COULTER EVERETT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER ENROLLMENT
Authorized Official - Prefix:
Authorized Official - First Name:BRIANA
Authorized Official - Middle Name:
Authorized Official - Last Name:MCWILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:800-828-2012
Mailing Address - Street 1:21430 TIMBERLAKE RD
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24502-7248
Mailing Address - Country:US
Mailing Address - Phone:434-944-0194
Mailing Address - Fax:
Practice Address - Street 1:3803 PEACHTREE AVE
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-6727
Practice Address - Country:US
Practice Address - Phone:910-799-6262
Practice Address - Fax:910-799-6261
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-22
Last Update Date:2020-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Single Specialty