Provider Demographics
NPI:1407179617
Name:PHILLIPS, MAULDREE D
Entity Type:Individual
Prefix:
First Name:MAULDREE
Middle Name:D
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 1:11521 131ST ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH OZONE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11420-2605
Mailing Address - Country:US
Mailing Address - Phone:718-529-3539
Mailing Address - Fax:
Practice Address - Street 1:11521 131ST ST
Practice Address - Street 2:
Practice Address - City:SOUTH OZONE PARK
Practice Address - State:NY
Practice Address - Zip Code:11420-2605
Practice Address - Country:US
Practice Address - Phone:718-529-3539
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-03
Last Update Date:2010-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY187797164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse