Provider Demographics
NPI:1811654007
Name:PHILLIPS, JOEL (FNP)
Entity type:Individual
Prefix:
First Name:JOEL
Middle Name:
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11422 W 1350 S
Mailing Address - Street 2:
Mailing Address - City:WANATAH
Mailing Address - State:IN
Mailing Address - Zip Code:46390-9730
Mailing Address - Country:US
Mailing Address - Phone:219-508-4319
Mailing Address - Fax:
Practice Address - Street 1:85 E US HIGHWAY 6
Practice Address - Street 2:
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46383-8947
Practice Address - Country:US
Practice Address - Phone:219-983-8300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-22
Last Update Date:2021-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28205262A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner