Provider Demographics
NPI:1851174783
Name:PHILLIPS, CHARLES KENNETH JR (FNP)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:KENNETH
Last Name:PHILLIPS
Suffix:JR
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:209 N CAMELLIA BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT VALLEY
Mailing Address - State:GA
Mailing Address - Zip Code:31030-3368
Mailing Address - Country:US
Mailing Address - Phone:478-822-0054
Mailing Address - Fax:478-822-0059
Practice Address - Street 1:209 N CAMELLIA BLVD
Practice Address - Street 2:
Practice Address - City:FORT VALLEY
Practice Address - State:GA
Practice Address - Zip Code:31030-3368
Practice Address - Country:US
Practice Address - Phone:478-822-0054
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-15
Last Update Date:2023-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN232230363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily