Provider Demographics
NPI:1609911254
Name:PHILLIPS, ROYETTA LAVERNE (REGISTERED NURSE)
Entity Type:Individual
Prefix:MS
First Name:ROYETTA
Middle Name:LAVERNE
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50072 S ANGELO CT
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48047
Mailing Address - Country:US
Mailing Address - Phone:586-948-3782
Mailing Address - Fax:
Practice Address - Street 1:CIRCLE OF LIFE PSY HOSPITAL
Practice Address - Street 2:1500 GRATIOT
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48207
Practice Address - Country:US
Practice Address - Phone:313-245-0600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704106196163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse