Provider Demographics
NPI:1205197027
Name:GEORGE, PHYLLIS SUE (LMT, STNA)
Entity Type:Individual
Prefix:MS
First Name:PHYLLIS
Middle Name:SUE
Last Name:GEORGE
Suffix:
Gender:F
Credentials:LMT, STNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1137 BAY CIRCLE
Mailing Address - Street 2:
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45801
Mailing Address - Country:US
Mailing Address - Phone:419-230-1694
Mailing Address - Fax:
Practice Address - Street 1:1137 BAY CIRCLE ST
Practice Address - Street 2:
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45801-2411
Practice Address - Country:US
Practice Address - Phone:419-230-1694
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-07
Last Update Date:2012-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH33 018370175L00000X
OH401227960411376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175L00000XOther Service ProvidersHomeopath
No376K00000XNursing Service Related ProvidersNurse's Aide