Provider Demographics
NPI:1386209369
Name:PHILLIPS, LIBBY BEATTY
Entity Type:Individual
Prefix:
First Name:LIBBY
Middle Name:BEATTY
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8804 ARLEY DR
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:22153-1501
Mailing Address - Country:US
Mailing Address - Phone:703-231-4990
Mailing Address - Fax:
Practice Address - Street 1:9380 FORESTWOOD LN STE B
Practice Address - Street 2:
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20110-4735
Practice Address - Country:US
Practice Address - Phone:703-335-2779
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-06
Last Update Date:2019-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024177140363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily