Provider Demographics
NPI:1598304958
Name:PHILLIP, SOPHIA A (FNP)
Entity Type:Individual
Prefix:MRS
First Name:SOPHIA
Middle Name:A
Last Name:PHILLIP
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:65 N MADISON AVE STE 800
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91101-2038
Mailing Address - Country:US
Mailing Address - Phone:626-792-3141
Mailing Address - Fax:
Practice Address - Street 1:65 N MADISON AVE STE 800
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91101-2038
Practice Address - Country:US
Practice Address - Phone:626-792-3141
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-03
Last Update Date:2020-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95012382363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily