Provider Demographics
NPI:1164414504
Name:PHILLIPS, MARY NELL (APN)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:NELL
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:MARY NELL
Other - Middle Name:
Other - Last Name:PHILLIPS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:APN
Mailing Address - Street 1:7714 POPLAR AVE. SUITE 200
Mailing Address - Street 2:ATTN: CREDENTIALING
Mailing Address - City:GERMANTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:38138-3941
Mailing Address - Country:US
Mailing Address - Phone:901-683-0055
Mailing Address - Fax:901-922-6722
Practice Address - Street 1:7945 WOLF RIVER BLVD
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:TN
Practice Address - Zip Code:38138-1762
Practice Address - Country:US
Practice Address - Phone:901-683-0055
Practice Address - Fax:901-685-2969
Is Sole Proprietor?:No
Enumeration Date:2005-08-22
Last Update Date:2017-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN5236363LF0000X
MSA810241363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS06429007Medicaid
AR150945758Medicaid
TN3909463Medicaid
MS06429007Medicaid
TN3909463Medicaid
MS06429007Medicaid
TN3909467Medicare PIN