Provider Demographics
NPI:1922455674
Name:BOB-HARRIS, PHYLLIS
Entity Type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:
Last Name:BOB-HARRIS
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:PHYLLIS
Other - Middle Name:YVETTE
Other - Last Name:BOB HARRIS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LVN
Mailing Address - Street 1:2108 PETUNIA ST
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75228-5685
Mailing Address - Country:US
Mailing Address - Phone:972-748-8485
Mailing Address - Fax:
Practice Address - Street 1:2108 PETUNIA ST
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75228-5685
Practice Address - Country:US
Practice Address - Phone:972-748-8485
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-23
Last Update Date:2016-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA202483164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse