Provider Demographics
NPI:1619754637
Name:PHELPS, GILLIAN JERLEEN (CSFA)
Entity Type:Individual
Prefix:
First Name:GILLIAN
Middle Name:JERLEEN
Last Name:PHELPS
Suffix:
Gender:F
Credentials:CSFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:74 HERMOSA DR
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:KY
Mailing Address - Zip Code:42503-5652
Mailing Address - Country:US
Mailing Address - Phone:704-775-6762
Mailing Address - Fax:
Practice Address - Street 1:305 LANGDON ST
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:KY
Practice Address - Zip Code:42503-2750
Practice Address - Country:US
Practice Address - Phone:606-679-7441
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-12
Last Update Date:2023-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYTSA057246ZS0410X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist