Provider Demographics
NPI:1952498065
Name:EGBERT, PHYLLIS (APRN)
Entity Type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:
Last Name:EGBERT
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 LANDRUM PL
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37043-6319
Mailing Address - Country:US
Mailing Address - Phone:931-245-2090
Mailing Address - Fax:931-245-2091
Practice Address - Street 1:311 LANDRUM PL
Practice Address - Street 2:SUITE 100
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37043-6319
Practice Address - Country:US
Practice Address - Phone:931-245-2090
Practice Address - Fax:931-245-2091
Is Sole Proprietor?:No
Enumeration Date:2006-10-09
Last Update Date:2008-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN05514363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
N/AMedicare UPIN