Provider Demographics
NPI:1407478209
Name:PHILLIPS, LAURA POLK (CRNA)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:POLK
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 STONE CREEK DR
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39110-5058
Mailing Address - Country:US
Mailing Address - Phone:662-207-3135
Mailing Address - Fax:
Practice Address - Street 1:125 STONE CREEK DR
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:MS
Practice Address - Zip Code:39110-5058
Practice Address - Country:US
Practice Address - Phone:662-207-3135
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-14
Last Update Date:2020-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS127477367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered