Provider Demographics
NPI:1437816543
Name:PHILLIPS, ANGELA
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:
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 1:4560 RANDOLPH ROAD
Mailing Address - Street 2:APT 112
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28211
Mailing Address - Country:US
Mailing Address - Phone:312-752-0106
Mailing Address - Fax:
Practice Address - Street 1:2821 EAST LANCASTER AVENUE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76103-7610
Practice Address - Country:US
Practice Address - Phone:312-752-0106
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-23
Last Update Date:2021-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
NAOtherNA