Provider Demographics
NPI:1104505684
Name:PHILLIPS, AUDREY M
Entity type:Individual
Prefix:MISS
First Name:AUDREY
Middle Name:M
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1499 CENTRAL PARK BLVD UNIT 1428
Mailing Address - Street 2:
Mailing Address - City:HARVEY
Mailing Address - State:LA
Mailing Address - Zip Code:70058-3691
Mailing Address - Country:US
Mailing Address - Phone:340-227-2662
Mailing Address - Fax:
Practice Address - Street 1:1499 CENTRAL PARK BLVD UNIT 1428
Practice Address - Street 2:
Practice Address - City:HARVEY
Practice Address - State:LA
Practice Address - Zip Code:70058-3691
Practice Address - Country:US
Practice Address - Phone:340-227-2662
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-13
Last Update Date:2023-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172A00000X
LA010925841172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver