Basic Information
| Provider Information | |||||||||
| NPI: | 1770681595 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PHELPS | ||||||||
| FirstName: | PHYLLIS | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | ARNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PATTEN | ||||||||
| OtherFirstName: | PHYLLIS | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | ARNP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1029 SHAWMUT ST S | ||||||||
| Address2: | |||||||||
| City: | SHAKOPEE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553792826 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9524454070 | ||||||||
| FaxNumber: | 9524451501 | ||||||||
| Practice Location | |||||||||
| Address1: | 1805 HENNEPIN AVE N | ||||||||
| Address2: | |||||||||
| City: | GLENCOE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553361416 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3208643121 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2006 | ||||||||
| LastUpdateDate: | 03/04/2019 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | CNP 4348 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | 9232460 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 307400500 | 05 | FL | MEDICAID |