Provider Demographics
NPI:1639234685
Name:PHILLIPS, SUSAN (CNM)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:
Other - Last Name:MENNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNM
Mailing Address - Street 1:1500 OGLETHORPE AVE
Mailing Address - Street 2:SUITE 600F
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30606-2179
Mailing Address - Country:US
Mailing Address - Phone:706-475-4917
Mailing Address - Fax:
Practice Address - Street 1:1199 PRINCE AVE
Practice Address - Street 2:MIDWFIERY CLINIC
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-2797
Practice Address - Country:US
Practice Address - Phone:706-475-4917
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-27
Last Update Date:2014-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN092464367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00484921AMedicaid