Provider Demographics
NPI:1801540679
Name:PHILLIPS, MACY BROOKE
Entity type:Individual
Prefix:
First Name:MACY
Middle Name:BROOKE
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 1:885 MAGNOLIA CT
Mailing Address - Street 2:
Mailing Address - City:COOKEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38501-4390
Mailing Address - Country:US
Mailing Address - Phone:931-409-4559
Mailing Address - Fax:
Practice Address - Street 1:315 N WASHINGTON AVE STE 130
Practice Address - Street 2:
Practice Address - City:COOKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38501-2623
Practice Address - Country:US
Practice Address - Phone:931-854-9880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-09
Last Update Date:2022-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN31056363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily