Provider Demographics
NPI:1487190203
Name:PHILLIPS, LINDA
Entity Type:Individual
Prefix:
First Name:LINDA
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 1:172 TOWNSHIP ROAD 2150
Mailing Address - Street 2:
Mailing Address - City:JEROMESVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44840-9615
Mailing Address - Country:US
Mailing Address - Phone:330-466-3343
Mailing Address - Fax:
Practice Address - Street 1:172 TOWNSHIP ROAD 2150
Practice Address - Street 2:
Practice Address - City:JEROMESVILLE
Practice Address - State:OH
Practice Address - Zip Code:44840-9615
Practice Address - Country:US
Practice Address - Phone:330-466-3343
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-18
Last Update Date:2017-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2681110374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH107536442099Medicaid