Provider Demographics
NPI:1356567069
Name:KILGORE, PHYLLIS TUCKER
Entity type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:TUCKER
Last Name:KILGORE
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 1:4627 RICKMAN RD
Mailing Address - Street 2:
Mailing Address - City:COOKEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38506-7731
Mailing Address - Country:US
Mailing Address - Phone:931-498-3642
Mailing Address - Fax:
Practice Address - Street 1:90 W 8TH ST
Practice Address - Street 2:
Practice Address - City:COOKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38505-0001
Practice Address - Country:US
Practice Address - Phone:931-372-3320
Practice Address - Fax:931-372-3848
Is Sole Proprietor?:No
Enumeration Date:2007-04-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN33008164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse