Provider Demographics
NPI:1619178670
Name:PHILLIPS, IETHA L (LPN)
Entity Type:Individual
Prefix:MS
First Name:IETHA
Middle Name:L
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1346 SHAWVIEW AVE.
Mailing Address - Street 2:
Mailing Address - City:E. CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44112
Mailing Address - Country:US
Mailing Address - Phone:216-761-1296
Mailing Address - Fax:
Practice Address - Street 1:1346 SHAWVIEW AVE.
Practice Address - Street 2:
Practice Address - City:E. CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44112-2720
Practice Address - Country:US
Practice Address - Phone:216-761-1296
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-29
Last Update Date:2008-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN1005082080H0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080H0002XAllopathic & Osteopathic PhysiciansPediatricsHospice and Palliative Medicine