Basic Information
Provider Information | |||||||||
NPI: | 1750961173 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PHILLIPS | ||||||||
FirstName: | KELLIE | ||||||||
MiddleName: | LEANNE | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | RN | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | PHILLIPS | ||||||||
OtherFirstName: | KELLIE | ||||||||
OtherMiddleName: | LEANNE | ||||||||
OtherNamePrefix: | MRS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | RN50420 | ||||||||
OtherLastNameType: | 2 | ||||||||
Mailing Information | |||||||||
Address1: | 3001 SAINT ROSE PKWY | ||||||||
Address2: |   | ||||||||
City: | HENDERSON | ||||||||
State: | NV | ||||||||
PostalCode: | 890523839 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7026165600 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 3001 SAINT ROSE PKWY | ||||||||
Address2: |   | ||||||||
City: | HENDERSON | ||||||||
State: | NV | ||||||||
PostalCode: | 890523839 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7026165000 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/09/2021 | ||||||||
LastUpdateDate: | 04/09/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/09/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WE0003X | RN50421 | NV | Y |   | Nursing Service Providers | Registered Nurse | Emergency |
ID Information
ID | Type | State | Issuer | Description | RN50420 | 01 | NV | LISCENSE NUMBEE | OTHER |