Provider Demographics
NPI:1831839349
Name:BUSH, PHYLICIA ELECTA
Entity type:Individual
Prefix:
First Name:PHYLICIA
Middle Name:ELECTA
Last Name:BUSH
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:PHYLICIA
Other - Middle Name:ELECTA
Other - Last Name:BUSH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:5655 LUNKER LN
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32303-6942
Mailing Address - Country:US
Mailing Address - Phone:866-459-8264
Mailing Address - Fax:866-459-8264
Practice Address - Street 1:5252 GRAVES ROAD
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32303
Practice Address - Country:US
Practice Address - Phone:866-459-8264
Practice Address - Fax:866-459-8264
Is Sole Proprietor?:No
Enumeration Date:2022-03-31
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL202C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes202C00000XAllopathic & Osteopathic PhysiciansIndependent Medical Examiner