Provider Demographics
NPI:1841785185
Name:PHILLIPS, CYNTHIA DAWN (APN)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:DAWN
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 1:4101 N WATER TOWER PL
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864-6296
Mailing Address - Country:US
Mailing Address - Phone:618-244-4313
Mailing Address - Fax:618-242-4337
Practice Address - Street 1:4101 N WATER TOWER PL
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-6296
Practice Address - Country:US
Practice Address - Phone:618-244-4313
Practice Address - Fax:618-242-4337
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-28
Last Update Date:2023-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209017522363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty