Provider Demographics
NPI:1396193405
Name:PHILLIPS, MARLOW (NP)
Entity type:Individual
Prefix:
First Name:MARLOW
Middle Name:
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:MARLOW
Other - Middle Name:KRISTINE
Other - Last Name:BRUNEAU
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2700 PROSPERITY AVE STE 270
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22031-4321
Mailing Address - Country:US
Mailing Address - Phone:703-698-2431
Mailing Address - Fax:
Practice Address - Street 1:3300 GALLOWS ROAD
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22042
Practice Address - Country:US
Practice Address - Phone:703-776-4001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-31
Last Update Date:2019-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024173545363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology