Provider Demographics
NPI:1386382851
Name:PHILLIP, LIAM JAMAL (LPN)
Entity type:Individual
Prefix:
First Name:LIAM
Middle Name:JAMAL
Last Name:PHILLIP
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:76 LAUREL AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10304-1931
Mailing Address - Country:US
Mailing Address - Phone:580-919-9938
Mailing Address - Fax:
Practice Address - Street 1:76 LAUREL AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10304-1931
Practice Address - Country:US
Practice Address - Phone:580-919-9938
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-24
Last Update Date:2022-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY324063164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse