Provider Demographics
NPI:1164474045
Name:PHILLIPS-BOHLENDER, MILISSA C (NP)
Entity Type:Individual
Prefix:
First Name:MILISSA
Middle Name:C
Last Name:PHILLIPS-BOHLENDER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6920 POINTE INVERNESS WAY STE 200
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-7934
Mailing Address - Country:US
Mailing Address - Phone:260-479-3514
Mailing Address - Fax:260-479-3520
Practice Address - Street 1:7900 W JEFFERSON BLVD STE 306
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-4128
Practice Address - Country:US
Practice Address - Phone:260-458-3610
Practice Address - Fax:260-458-3611
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2020-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71001697A363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200310160Medicaid
Q25233Medicare UPIN
INM400069967Medicare PIN
INQ25233Medicare UPIN
Q25233Medicare UPIN
IN925060IIIIMedicare ID - Type Unspecified