Provider Demographics
NPI:1255179487
Name:PHILLIPS, LIZA
Entity type:Individual
Prefix:
First Name:LIZA
Middle Name:
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5122 MOSER DR
Mailing Address - Street 2:
Mailing Address - City:BALL
Mailing Address - State:LA
Mailing Address - Zip Code:71405-3668
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5122 MOSER DR
Practice Address - Street 2:
Practice Address - City:BALL
Practice Address - State:LA
Practice Address - Zip Code:71405-3668
Practice Address - Country:US
Practice Address - Phone:740-222-2666
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-20
Last Update Date:2024-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA916109367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered