Provider Demographics
NPI:1134733397
Name:PHILLIPS, EDNA RENEE
Entity type:Individual
Prefix:
First Name:EDNA
Middle Name:RENEE
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:EDNA
Other - Middle Name:RENEE
Other - Last Name:DOFFONEY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:EDNA PHILLIPS,CEO
Mailing Address - Street 1:3352 JAN CT
Mailing Address - Street 2:
Mailing Address - City:KATY
Mailing Address - State:TX
Mailing Address - Zip Code:77493-1379
Mailing Address - Country:US
Mailing Address - Phone:409-363-3166
Mailing Address - Fax:
Practice Address - Street 1:3352 JAN CT
Practice Address - Street 2:
Practice Address - City:KATY
Practice Address - State:TX
Practice Address - Zip Code:77493-1379
Practice Address - Country:US
Practice Address - Phone:409-363-3166
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-04
Last Update Date:2020-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372600000XNursing Service Related ProvidersAdult Companion
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX85-2484116Medicaid