Provider Demographics
NPI:1770681595
Name:PHELPS, PHYLLIS L (ARNP)
Entity Type:Individual
Prefix:MS
First Name:PHYLLIS
Middle Name:L
Last Name:PHELPS
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:PHYLLIS
Other - Middle Name:
Other - Last Name:PATTEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ARNP
Mailing Address - Street 1:1029 SHAWMUT ST S
Mailing Address - Street 2:
Mailing Address - City:SHAKOPEE
Mailing Address - State:MN
Mailing Address - Zip Code:55379-2826
Mailing Address - Country:US
Mailing Address - Phone:952-445-4070
Mailing Address - Fax:952-445-1501
Practice Address - Street 1:1805 HENNEPIN AVE N
Practice Address - Street 2:
Practice Address - City:GLENCOE
Practice Address - State:MN
Practice Address - Zip Code:55336-1416
Practice Address - Country:US
Practice Address - Phone:320-864-3121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2019-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNCNP 4348363LF0000X
FL9232460363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL307400500Medicaid
Q05193Medicare UPIN