Provider Demographics
NPI:1215528997
Name:LOUGHEED, PHILLIP GLENN (FNP-BC, RN)
Entity type:Individual
Prefix:
First Name:PHILLIP
Middle Name:GLENN
Last Name:LOUGHEED
Suffix:
Gender:M
Credentials:FNP-BC, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:413 WALNUT AVE
Mailing Address - Street 2:
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48073-5310
Mailing Address - Country:US
Mailing Address - Phone:810-938-8201
Mailing Address - Fax:
Practice Address - Street 1:24255 W 13 MILE RD
Practice Address - Street 2:
Practice Address - City:BINGHAM FARMS
Practice Address - State:MI
Practice Address - Zip Code:48025-4320
Practice Address - Country:US
Practice Address - Phone:248-723-9613
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-27
Last Update Date:2021-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIF10201475363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner