Basic Information
Provider Information | |||||||||
NPI: | 1205972544 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PHILLIPS | ||||||||
FirstName: | ALISHA | ||||||||
MiddleName: | LORRAINE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | FNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 823 CENTER AVE | ||||||||
Address2: |   | ||||||||
City: | PAYETTE | ||||||||
State: | ID | ||||||||
PostalCode: | 836612535 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2086423396 | ||||||||
FaxNumber: | 2086429060 | ||||||||
Practice Location | |||||||||
Address1: | 823 CENTER AVE | ||||||||
Address2: |   | ||||||||
City: | PAYETTE | ||||||||
State: | ID | ||||||||
PostalCode: | 836612535 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2086423396 | ||||||||
FaxNumber: | 2086429060 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/30/2007 | ||||||||
LastUpdateDate: | 06/14/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/14/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | N-19189 | ID | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
ID | Type | State | Issuer | Description | NPPU5 | 01 |   | BLUE CROSS | OTHER | 820525763 | 01 |   | COMMERCIAL | OTHER | 806957500 | 05 | ID |   | MEDICAID | 000010147752 | 01 |   | REGENCE BLUE SHIELD | OTHER | 278542 | 05 | OR |   | MEDICAID |