Provider Demographics
NPI:1578890752
Name:PHILLIPS, TRACI MARLENA (BSN,RN,MSN,FNP-BC)
Entity Type:Individual
Prefix:
First Name:TRACI
Middle Name:MARLENA
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:BSN,RN,MSN,FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1680
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25717-1680
Mailing Address - Country:US
Mailing Address - Phone:304-528-6445
Mailing Address - Fax:304-528-5220
Practice Address - Street 1:723 9TH AVE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25701-2718
Practice Address - Country:US
Practice Address - Phone:045-290-6453
Practice Address - Fax:304-529-3026
Is Sole Proprietor?:No
Enumeration Date:2009-11-10
Last Update Date:2020-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV66503363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3040355Medicaid
WV3810017383Medicaid
KY7100116110Medicaid
WVWV2731EMedicare PIN
WV3810017383Medicaid
OH3040355Medicaid
WVWV2731CMedicare PIN
WVWV2731C437Medicare PIN
WVWV2731BMedicare PIN
WVWV2731C455Medicare PIN
WVWV2731AMedicare PIN
WVWV2731C895Medicare PIN
WVWV2731Medicare PIN