Provider Demographics
NPI:1194021212
Name:ST. PHILLIPS, GREGORY ALFRED (LPN)
Entity Type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:ALFRED
Last Name:ST. PHILLIPS
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1964 CALEB AVE
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13206-2519
Mailing Address - Country:US
Mailing Address - Phone:315-433-1255
Mailing Address - Fax:
Practice Address - Street 1:1964 CALEB AVE
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13206-2519
Practice Address - Country:US
Practice Address - Phone:315-433-1255
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-07
Last Update Date:2011-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY293594-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse