Provider Demographics
NPI:1790049831
Name:PHILLIPS, JULIA LYNN (REGISTERED)
Entity Type:Individual
Prefix:MS
First Name:JULIA
Middle Name:LYNN
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:REGISTERED
Other - Prefix:MS
Other - First Name:JULIA
Other - Middle Name:LYNN
Other - Last Name:PHILLIPS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:REGISTERED DIETECHNS
Mailing Address - Street 1:321 BIG ARCH RD
Mailing Address - Street 2:
Mailing Address - City:GODFREY
Mailing Address - State:IL
Mailing Address - Zip Code:62035
Mailing Address - Country:US
Mailing Address - Phone:618-973-5832
Mailing Address - Fax:618-433-1556
Practice Address - Street 1:321 BIG ARCH RD
Practice Address - Street 2:
Practice Address - City:GODFREY
Practice Address - State:IL
Practice Address - Zip Code:62035
Practice Address - Country:US
Practice Address - Phone:618-973-5832
Practice Address - Fax:618-433-1556
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-03
Last Update Date:2012-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes136A00000XDietary & Nutritional Service ProvidersDietetic Technician, Registered