Provider Demographics
NPI:1750051934
Name:PHILLIPS, SHERESE D (ADMINISTRATOR)
Entity Type:Individual
Prefix:
First Name:SHERESE
Middle Name:D
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:ADMINISTRATOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3543 HIGHWAY 67 W
Mailing Address - Street 2:
Mailing Address - City:HOPE
Mailing Address - State:AR
Mailing Address - Zip Code:71801-8858
Mailing Address - Country:US
Mailing Address - Phone:870-703-5525
Mailing Address - Fax:
Practice Address - Street 1:3543 HIGHWAY 67 W
Practice Address - Street 2:
Practice Address - City:HOPE
Practice Address - State:AR
Practice Address - Zip Code:71801-8858
Practice Address - Country:US
Practice Address - Phone:870-703-5525
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-17
Last Update Date:2021-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility