Provider Demographics
NPI:1245474097
Name:PHILLIPS, SHARON ELAINE (LVN/LPN)
Entity type:Individual
Prefix:
First Name:SHARON
Middle Name:ELAINE
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:LVN/LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12975 MORENO BEACH DR
Mailing Address - Street 2:11206
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92555-4427
Mailing Address - Country:US
Mailing Address - Phone:813-235-5348
Mailing Address - Fax:
Practice Address - Street 1:12975 MORENO BEACH DR
Practice Address - Street 2:11206
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92555-4427
Practice Address - Country:US
Practice Address - Phone:813-235-5348
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-23
Last Update Date:2009-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN235929164X00000X, 374700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse
No374700000XNursing Service Related ProvidersTechnician