Provider Demographics
NPI:1780672741
Name:PHILLIPS, PAULA BERYL (ARNP)
Entity Type:Individual
Prefix:MS
First Name:PAULA
Middle Name:BERYL
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6910 OLD WOLF BAY RD
Mailing Address - Street 2:KIDS CARE PEDIATRICS, PA
Mailing Address - City:PALATKA
Mailing Address - State:FL
Mailing Address - Zip Code:32177-6800
Mailing Address - Country:US
Mailing Address - Phone:386-328-7337
Mailing Address - Fax:
Practice Address - Street 1:6910 OLD WOLF BAY RD
Practice Address - Street 2:KIDS CARE PEDIATRICS, PA
Practice Address - City:PALATKA
Practice Address - State:FL
Practice Address - Zip Code:32177-6800
Practice Address - Country:US
Practice Address - Phone:386-328-7337
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-12
Last Update Date:2011-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP2609432363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL301680300Medicaid