Basic Information
| Provider Information | |||||||||
| NPI: | 1063819308 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PHILLIPS | ||||||||
| FirstName: | TAMARA | ||||||||
| MiddleName: | KACEY | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | R.N. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WEBBER | ||||||||
| OtherFirstName: | TAMARA | ||||||||
| OtherMiddleName: | KACEY | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 15001 E. OXFORD AVE | ||||||||
| Address2: | |||||||||
| City: | AURORA | ||||||||
| State: | CO | ||||||||
| PostalCode: | 80014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3036931550 | ||||||||
| FaxNumber: | 3036935481 | ||||||||
| Practice Location | |||||||||
| Address1: | 15001 E. OXFORD AVE | ||||||||
| Address2: | EXCELSIOR YOUTH CENTER | ||||||||
| City: | AURORA | ||||||||
| State: | CO | ||||||||
| PostalCode: | 80014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3036931550 | ||||||||
| FaxNumber: | 3036935481 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/02/2014 | ||||||||
| LastUpdateDate: | 12/02/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | RN0165225 | CO | Y | Nursing Service Providers | Registered Nurse |
No ID Information.