Provider Demographics
NPI:1568015584
Name:PHILLIPS, LORI J (CPNP)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:J
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1602 KINGS HWY
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71103-4128
Mailing Address - Country:US
Mailing Address - Phone:318-626-0050
Mailing Address - Fax:318-675-6145
Practice Address - Street 1:1602 KINGS HWY
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103-4128
Practice Address - Country:US
Practice Address - Phone:318-626-0050
Practice Address - Fax:318-675-6145
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-18
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA207297363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics