Provider Demographics
NPI:1891173324
Name:PHILLIPS, REGINA D
Entity Type:Individual
Prefix:MS
First Name:REGINA
Middle Name:D
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:REGINA
Other - Middle Name:D
Other - Last Name:THOMAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1011 EAGLES RIDGE CT
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30043-2825
Mailing Address - Country:US
Mailing Address - Phone:513-237-8098
Mailing Address - Fax:
Practice Address - Street 1:1011 EAGLES RIDGE CT
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30043-4196
Practice Address - Country:US
Practice Address - Phone:513-237-8089
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-17
Last Update Date:2016-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA431983029343900000X, 347C00000X, 1744P3200X
GARN232977163W00000X
OH4319830291744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No347C00000XTransportation ServicesPrivate Vehicle
No1744P3200XOther Service ProvidersSpecialistProsthetics Case Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA4319893029Medicaid
GA813745446Medicaid