Provider Demographics
NPI:1396053484
Name:PHIPPS, MARY JANE (FNP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:JANE
Last Name:PHIPPS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7400 LYNN AVE
Mailing Address - Street 2:
Mailing Address - City:HAMLIN
Mailing Address - State:WV
Mailing Address - Zip Code:25523-1138
Mailing Address - Country:US
Mailing Address - Phone:304-824-5806
Mailing Address - Fax:304-824-5804
Practice Address - Street 1:202 LARRY JOE HARLESS DR
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:WV
Practice Address - Zip Code:25621
Practice Address - Country:US
Practice Address - Phone:304-664-6270
Practice Address - Fax:304-664-6272
Is Sole Proprietor?:No
Enumeration Date:2010-09-22
Last Update Date:2019-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV50819363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810021064Medicaid
WVWV0603FMedicare Oscar/Certification
WVWV0603AMedicare PIN
WVWV0603DMedicare Oscar/Certification
WVWV0603BMedicare Oscar/Certification
WVWV0603B662Medicare Oscar/Certification
WVWV0603EMedicare Oscar/Certification
WVWV0603GMedicare Oscar/Certification
WVWV0603B663Medicare Oscar/Certification
WVWV0603CMedicare Oscar/Certification
WVWV0603HMedicare Oscar/Certification