Provider Demographics
NPI:1780231969
Name:PHILLIPS, SHRONDA ANN (APN)
Entity Type:Individual
Prefix:
First Name:SHRONDA
Middle Name:ANN
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9727
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61612-9727
Mailing Address - Country:US
Mailing Address - Phone:309-886-9172
Mailing Address - Fax:
Practice Address - Street 1:3525 N UNIVERSITY ST
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61604-1324
Practice Address - Country:US
Practice Address - Phone:309-886-9172
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-21
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209018934363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner