Provider Demographics
NPI:1245424746
Name:SIM, PHYLLIS A (CFNP)
Entity Type:Individual
Prefix:MRS
First Name:PHYLLIS
Middle Name:A
Last Name:SIM
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:207 WEST HIGH STREET
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:OH
Mailing Address - Zip Code:43050
Mailing Address - Country:US
Mailing Address - Phone:740-392-1181
Mailing Address - Fax:740-392-1180
Practice Address - Street 1:207 WEST HIGH STREET
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:OH
Practice Address - Zip Code:43050
Practice Address - Country:US
Practice Address - Phone:740-392-1181
Practice Address - Fax:740-392-1180
Is Sole Proprietor?:No
Enumeration Date:2007-08-28
Last Update Date:2012-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN214125363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3104269Medicaid
OH1414060472Medicare PIN