Provider Demographics
NPI:1811701915
Name:PHILLIPS, LATORIE MICHELLE (RN, BSN)
Entity type:Individual
Prefix:
First Name:LATORIE
Middle Name:MICHELLE
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:RN, BSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:514 CHADMON COURT TRCE
Mailing Address - Street 2:
Mailing Address - City:DACULA
Mailing Address - State:GA
Mailing Address - Zip Code:30019-7070
Mailing Address - Country:US
Mailing Address - Phone:941-681-5138
Mailing Address - Fax:
Practice Address - Street 1:514 CHADMON COURT TRCE
Practice Address - Street 2:
Practice Address - City:DACULA
Practice Address - State:GA
Practice Address - Zip Code:30019-7070
Practice Address - Country:US
Practice Address - Phone:941-681-5138
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-07
Last Update Date:2025-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9480689163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse