Provider Demographics
NPI:1972609774
Name:PHILLIPS, ETTA J (MS,RD,LD)
Entity Type:Individual
Prefix:MS
First Name:ETTA
Middle Name:J
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:MS,RD,LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1550 KIPLING DR
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45406-4227
Mailing Address - Country:US
Mailing Address - Phone:937-275-7185
Mailing Address - Fax:
Practice Address - Street 1:1550 KIPLING DR
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45406-4227
Practice Address - Country:US
Practice Address - Phone:937-275-7185
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1853133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist