Provider Demographics
NPI:1235446972
Name:PHILLIPS, STACY (RN)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2150 CORBIN AVE
Mailing Address - Street 2:
Mailing Address - City:NEW BRITAIN
Mailing Address - State:CT
Mailing Address - Zip Code:06053-2266
Mailing Address - Country:US
Mailing Address - Phone:860-832-6248
Mailing Address - Fax:
Practice Address - Street 1:2150 CORBIN AVE
Practice Address - Street 2:
Practice Address - City:NEW BRITAIN
Practice Address - State:CT
Practice Address - Zip Code:06053-2266
Practice Address - Country:US
Practice Address - Phone:860-832-6248
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-01
Last Update Date:2022-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT004501363LA2100X
CT075385163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice