Provider Demographics
NPI:1487684981
Name:PHILLIPS, MARY CAROL (CRNP)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:CAROL
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:180 1/2 HIGHVIEW DR
Mailing Address - Street 2:
Mailing Address - City:UPPER ST CLAIR
Mailing Address - State:PA
Mailing Address - Zip Code:15241-1637
Mailing Address - Country:US
Mailing Address - Phone:412-833-9808
Mailing Address - Fax:724-250-7568
Practice Address - Street 1:100 RIDGE AVE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:PA
Practice Address - Zip Code:15301-3449
Practice Address - Country:US
Practice Address - Phone:724-250-7790
Practice Address - Fax:724-250-7568
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATP003855B363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PATP003855BOtherLICENCE