Basic Information
| Provider Information | |||||||||
| NPI: | 1336111327 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PHILLIPS | ||||||||
| FirstName: | ALICE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | FNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PHILLIPS | ||||||||
| OtherFirstName: | ALICE | ||||||||
| OtherMiddleName: | MARY | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3581 PALMER DR | ||||||||
| Address2: | SUITE 602 | ||||||||
| City: | CAMERON PARK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956828239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5306262920 | ||||||||
| FaxNumber: | 5306727047 | ||||||||
| Practice Location | |||||||||
| Address1: | 3581 PALMER DR | ||||||||
| Address2: | SUITE 602 | ||||||||
| City: | CAMERON PARK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956828239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5306262920 | ||||||||
| FaxNumber: | 5306727047 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/03/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 277298 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.