Provider Demographics
NPI:1912102492
Name:PHILLIPS, ELLICENE R (ARNP)
Entity Type:Individual
Prefix:MS
First Name:ELLICENE
Middle Name:R
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:MS
Other - First Name:ELLICENE
Other - Middle Name:ROUNDTREE
Other - Last Name:PHILLIPS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2000 TOWERSIDE TER # 1410 # T2
Mailing Address - Street 2:
Mailing Address - City:MIAMI SHORES
Mailing Address - State:FL
Mailing Address - Zip Code:33138-2244
Mailing Address - Country:US
Mailing Address - Phone:786-390-8579
Mailing Address - Fax:
Practice Address - Street 1:2000 TOWERSIDE TER # 1410 # T2
Practice Address - Street 2:
Practice Address - City:MIAMI SHORES
Practice Address - State:FL
Practice Address - Zip Code:33138-2244
Practice Address - Country:US
Practice Address - Phone:786-390-8579
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-15
Last Update Date:2014-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL332B00000X
FL446112363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL30231760Medicaid
FL30231760Medicaid