Provider Demographics
NPI:1679852438
Name:BIRT, PHYLLIS (LPN)
Entity Type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:
Last Name:BIRT
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 1:4331 THURMOND TANNER RD
Mailing Address - Street 2:
Mailing Address - City:FLOWERY BRANCH
Mailing Address - State:GA
Mailing Address - Zip Code:30542-2829
Mailing Address - Country:US
Mailing Address - Phone:678-513-5700
Mailing Address - Fax:678-513-5836
Practice Address - Street 1:915 INTERSTATE RIDGE DR
Practice Address - Street 2:SUITE G
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-7076
Practice Address - Country:US
Practice Address - Phone:678-513-5700
Practice Address - Fax:678-513-5836
Is Sole Proprietor?:No
Enumeration Date:2011-08-11
Last Update Date:2011-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPN031752164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse