Basic Information
| Provider Information | |||||||||
| NPI: | 1649245960 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PHILLIPS | ||||||||
| FirstName: | JONNIE | ||||||||
| MiddleName: | S | ||||||||
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| NameSuffix: | |||||||||
| Credential: | NURSE PRACTITIONER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3747 W FORK RD | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452477548 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5139614335 | ||||||||
| FaxNumber: | 5139614227 | ||||||||
| Practice Location | |||||||||
| Address1: | 3747 W FORK RD | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452477548 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5139614335 | ||||||||
| FaxNumber: | 5139614227 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/21/2006 | ||||||||
| LastUpdateDate: | 04/17/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 08008 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 200517900 | 05 | IN | MEDICAID | 2535993 | 05 | OH | MEDICAID | 78014164 | 05 | KY | MEDICAID | P00316324 | 01 | RAIL ROAD MEDICARE | OTHER | 200517900A | 05 | IN | MEDICAID | 7100056850 | 05 | KY | MEDICAID |