Provider Demographics
NPI:1275400871
Name:PHILLIPS, MAKITA
Entity type:Individual
Prefix:
First Name:MAKITA
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 1:1330 US HIGHWAY 319 N LOT 82
Mailing Address - Street 2:
Mailing Address - City:NORMAN PARK
Mailing Address - State:GA
Mailing Address - Zip Code:31771-6120
Mailing Address - Country:US
Mailing Address - Phone:770-750-5476
Mailing Address - Fax:
Practice Address - Street 1:119 W CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:MOULTRIE
Practice Address - State:GA
Practice Address - Zip Code:31768-3859
Practice Address - Country:US
Practice Address - Phone:770-750-5476
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-10-20
Last Update Date:2025-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACN0030095152374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374U00000XNursing Service Related ProvidersHome Health AideGroup - Multi-Specialty