Basic Information
Provider Information
NPI: 1942260823
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: PHILLIPS
FirstName: ROSALEE
MiddleName: M
NamePrefix: MS.
NameSuffix:  
Credential: CRNA
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: PO BOX 44008
Address2: UFJP PROVIDER ENROLLMENT
City: JACKSONVILLE
State: FL
PostalCode: 322314008
CountryCode: US
TelephoneNumber: 9042443199
FaxNumber: 9042443425
Practice Location
Address1: 655 W 8TH ST
Address2: UFJP ANESTHESIA DEPT
City: JACKSONVILLE
State: FL
PostalCode: 322096511
CountryCode: US
TelephoneNumber: 9042444195
FaxNumber: 9042444908
Other Information
ProviderEnumerationDate: 03/24/2006
LastUpdateDate: 03/20/2013
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
367500000XARNP1423952FLY Physician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered 

ID Information
IDTypeStateIssuerDescription
000882758A05GA MEDICAID
3025292-0005FL MEDICAID
000882758B05FL MEDICAID


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