Provider Demographics
NPI:1194505453
Name:PHILLIPS, DONNA JEAN
Entity type:Individual
Prefix:
First Name:DONNA
Middle Name:JEAN
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 1:1907 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WELLSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26070-1437
Mailing Address - Country:US
Mailing Address - Phone:304-737-4384
Mailing Address - Fax:
Practice Address - Street 1:1907 MAIN ST
Practice Address - Street 2:
Practice Address - City:WELLSBURG
Practice Address - State:WV
Practice Address - Zip Code:26070-1437
Practice Address - Country:US
Practice Address - Phone:304-737-4384
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-04
Last Update Date:2023-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV125553494Medicaid
WV1821206228Medicaid
WV1356607394Medicaid