Provider Demographics
NPI:1932145042
Name:PHILLIPS, HEATHER L (CRNA)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:L
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:L
Other - Last Name:FAZAKERLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11781 LEE JACKSON MEMORIAL HWY
Mailing Address - Street 2:STE 550
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22033-3309
Mailing Address - Country:US
Mailing Address - Phone:571-777-5164
Mailing Address - Fax:703-890-2650
Practice Address - Street 1:100 GRAND ST
Practice Address - Street 2:
Practice Address - City:NEW BRITAIN
Practice Address - State:CT
Practice Address - Zip Code:06052-2016
Practice Address - Country:US
Practice Address - Phone:860-224-5011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2015-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC181281367500000X
CT004328367500000X
CT092714163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
41650OtherAANA
41650OtherAANA