Provider Demographics
NPI:1659362085
Name:PHILLIPS, SUSAN K (FNP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:K
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4001 WABASH AVE
Mailing Address - Street 2:
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47803-1678
Mailing Address - Country:US
Mailing Address - Phone:812-238-7788
Mailing Address - Fax:812-238-4508
Practice Address - Street 1:4001 WABASH AVE
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47803-1678
Practice Address - Country:US
Practice Address - Phone:812-238-7788
Practice Address - Fax:812-238-4508
Is Sole Proprietor?:No
Enumeration Date:2005-11-03
Last Update Date:2016-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71001696363L00000X
IN28112100A363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200520070Medicaid
INP00431348OtherRR MEDICARE
IN854700YYYMedicare PIN
Q47414Medicare UPIN
IN254390FMedicare PIN
INP00431348OtherRR MEDICARE
IN130910IMedicare PIN
IN200520070Medicaid