Provider Demographics
NPI:1124141635
Name:PHILLIPS, TERESA ELAINE (LPN)
Entity type:Individual
Prefix:
First Name:TERESA
Middle Name:ELAINE
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1565
Mailing Address - Street 2:1394 DANIEL RD
Mailing Address - City:DEMOREST
Mailing Address - State:GA
Mailing Address - Zip Code:30535-1565
Mailing Address - Country:US
Mailing Address - Phone:706-778-7156
Mailing Address - Fax:
Practice Address - Street 1:185 SCOGGINS DR
Practice Address - Street 2:
Practice Address - City:DEMOREST
Practice Address - State:GA
Practice Address - Zip Code:30535-5355
Practice Address - Country:US
Practice Address - Phone:706-778-7156
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPN046244164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse