Provider Demographics
NPI:1982146817
Name:PHELPS, LILLIE
Entity Type:Individual
Prefix:
First Name:LILLIE
Middle Name:
Last Name:PHELPS
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 1:418 N ANN ARBOR ST
Mailing Address - Street 2:
Mailing Address - City:SALINE
Mailing Address - State:MI
Mailing Address - Zip Code:48176-1032
Mailing Address - Country:US
Mailing Address - Phone:734-883-1548
Mailing Address - Fax:
Practice Address - Street 1:418 N ANN ARBOR ST
Practice Address - Street 2:
Practice Address - City:SALINE
Practice Address - State:MI
Practice Address - Zip Code:48176-1032
Practice Address - Country:US
Practice Address - Phone:734-883-1548
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-09
Last Update Date:2016-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIP412522135964247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other