Provider Demographics
NPI:1356957724
Name:PHIPPS, TINA DANIELLE
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:DANIELLE
Last Name:PHIPPS
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 1:2191 JOHNSON AVE
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-4534
Mailing Address - Country:US
Mailing Address - Phone:805-473-7067
Mailing Address - Fax:
Practice Address - Street 1:2191 JOHNSON AVE
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-4534
Practice Address - Country:US
Practice Address - Phone:805-473-7067
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-21
Last Update Date:2020-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA725182163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management