Provider Demographics
NPI:1679872857
Name:PHILLIPS, CARLISA JANE (APRN-CNP)
Entity Type:Individual
Prefix:
First Name:CARLISA
Middle Name:JANE
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:APRN-CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5840 S MEMORIAL DR STE 301
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74145-9082
Mailing Address - Country:US
Mailing Address - Phone:918-699-4250
Mailing Address - Fax:918-921-8824
Practice Address - Street 1:5840 S MEMORIAL DR STE 301
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74145-9082
Practice Address - Country:US
Practice Address - Phone:918-699-4250
Practice Address - Fax:918-921-8824
Is Sole Proprietor?:No
Enumeration Date:2011-03-27
Last Update Date:2022-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK64636363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200335850AMedicaid