Provider Demographics
NPI:1336668730
Name:ROZANSKY, PHILLISSA KAY
Entity Type:Individual
Prefix:
First Name:PHILLISSA
Middle Name:KAY
Last Name:ROZANSKY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:PHILLISSA
Other - Middle Name:KAY
Other - Last Name:SIMPSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:190 E BANNOCK ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83712-6241
Practice Address - Country:US
Practice Address - Phone:303-717-4168
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-17
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CORN.0124082363LN0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal
Provider Identifiers
StateIdentifier IDID TypeIssuer
CORN.0124082OtherRN LICENSE