Provider Demographics
NPI:1639263650
Name:PHILLIPS, MARY LEE (APRN, FNP)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:LEE
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:APRN, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 24308
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-4494
Mailing Address - Country:US
Mailing Address - Phone:307-995-8100
Mailing Address - Fax:307-995-8100
Practice Address - Street 1:720 LINDSAY LANE
Practice Address - Street 2:SUITE B
Practice Address - City:CODY
Practice Address - State:WY
Practice Address - Zip Code:82414
Practice Address - Country:US
Practice Address - Phone:307-578-1945
Practice Address - Fax:307-578-1956
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2018-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY26461.0975363LF0000X
WV33320363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVP00265315OtherRAILROAD MEDICARE
WV7103229000Medicaid
WV001721127OtherBCBS SERVICE NUMBER
WVS99556Medicare UPIN
WV7103229000Medicaid
WVPHNP19122Medicare PIN