Basic Information
| Provider Information | |||||||||
| NPI: | 1225320245 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DAVIS | ||||||||
| FirstName: | PHYLLIS | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 772 | ||||||||
| Address2: | MINUTECLINIC CREDENTIALING | ||||||||
| City: | WOONSOCKET | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028950784 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8663892727 | ||||||||
| FaxNumber: | 4016529787 | ||||||||
| Practice Location | |||||||||
| Address1: | 183 US HIGHWAY 206 S | ||||||||
| Address2: | |||||||||
| City: | CHESTER | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 079302402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8663892727 | ||||||||
| FaxNumber: | 4016529787 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2011 | ||||||||
| LastUpdateDate: | 08/26/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 26NJ00320600 | NJ | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | SP011233 | PA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.