Provider Demographics
NPI:1942734926
Name:PHILLIPS, SALLY LEE (RN)
Entity Type:Individual
Prefix:MRS
First Name:SALLY
Middle Name:LEE
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:SALLY
Other - Middle Name:LEE
Other - Last Name:PHILLIPS-SOARES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RN
Mailing Address - Street 1:960 BOARDMAN CANFIELD RD
Mailing Address - Street 2:
Mailing Address - City:BOARDMAN
Mailing Address - State:OH
Mailing Address - Zip Code:44512-4220
Mailing Address - Country:US
Mailing Address - Phone:330-953-3300
Mailing Address - Fax:
Practice Address - Street 1:960 BOARDMAN CANFIELD RD
Practice Address - Street 2:
Practice Address - City:BOARDMAN
Practice Address - State:OH
Practice Address - Zip Code:44512-4220
Practice Address - Country:US
Practice Address - Phone:330-953-3300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-17
Last Update Date:2018-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLPN.150607.MEDS-IV164W00000X
OHRN.448686163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No164W00000XNursing Service ProvidersLicensed Practical Nurse