Provider Demographics
NPI:1477209609
Name:PHILLIPS, BERNADETTE ANN
Entity Type:Individual
Prefix:
First Name:BERNADETTE
Middle Name:ANN
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 1:5300 ROSELAND AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89130-2635
Mailing Address - Country:US
Mailing Address - Phone:702-349-0358
Mailing Address - Fax:
Practice Address - Street 1:5300 ROSELAND AVE
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89130-2635
Practice Address - Country:US
Practice Address - Phone:702-349-0358
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-25
Last Update Date:2022-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
No251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV880782977Medicaid