Provider Demographics
NPI:1306027255
Name:LANDERS, PHYLLIS NADEAU (NP-C)
Entity Type:Individual
Prefix:MRS
First Name:PHYLLIS
Middle Name:NADEAU
Last Name:LANDERS
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:PHYLLIS
Other - Middle Name:ANNE
Other - Last Name:NADEAU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP-C
Mailing Address - Street 1:PO BOX 658
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30503-0658
Mailing Address - Country:US
Mailing Address - Phone:770-718-1122
Mailing Address - Fax:770-535-7445
Practice Address - Street 1:4222 FAIRBANKS DR
Practice Address - Street 2:
Practice Address - City:OAKWOOD
Practice Address - State:GA
Practice Address - Zip Code:30566-2811
Practice Address - Country:US
Practice Address - Phone:770-534-6053
Practice Address - Fax:770-534-6695
Is Sole Proprietor?:No
Enumeration Date:2007-11-20
Last Update Date:2011-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN096607363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA01372617OtherAMERIGROUP
GA701221561AMedicaid
GA563030OtherWELLCARE OF GEORGIA
202I502382Medicare PIN