Provider Demographics
NPI:1669572848
Name:PHILLIPS, KELLY SUSAN (CPNP)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:SUSAN
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 BRIGHTON RD
Mailing Address - Street 2:
Mailing Address - City:REHOBOTH BEACH
Mailing Address - State:DE
Mailing Address - Zip Code:19971-3526
Mailing Address - Country:US
Mailing Address - Phone:302-226-2877
Mailing Address - Fax:
Practice Address - Street 1:424 MULBERRY ST
Practice Address - Street 2:SUITE 1
Practice Address - City:MILTON
Practice Address - State:DE
Practice Address - Zip Code:19968-1628
Practice Address - Country:US
Practice Address - Phone:302-684-0561
Practice Address - Fax:302-684-3563
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2009-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEMP14450167363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
DEQ36949Medicare UPIN