Provider Demographics
NPI:1487673901
Name:PHILLIPPS, KAREN
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:
Last Name:PHILLIPPS
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 1:851 CHALET SUZANNE RD
Mailing Address - Street 2:
Mailing Address - City:LAKE WALES
Mailing Address - State:FL
Mailing Address - Zip Code:33859-7759
Mailing Address - Country:US
Mailing Address - Phone:863-679-9916
Mailing Address - Fax:863-679-9826
Practice Address - Street 1:851 CHALET SUZANNE RD
Practice Address - Street 2:
Practice Address - City:LAKE WALES
Practice Address - State:FL
Practice Address - Zip Code:33859-7759
Practice Address - Country:US
Practice Address - Phone:863-679-9916
Practice Address - Fax:863-679-9826
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2012-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME88539207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
H96361Medicare UPIN