Provider Demographics
NPI:1720145071
Name:PHILLIPS, WENDY SUE (DC)
Entity type:Individual
Prefix:
First Name:WENDY
Middle Name:SUE
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 261
Mailing Address - Street 2:
Mailing Address - City:RYDAL
Mailing Address - State:GA
Mailing Address - Zip Code:30171-0261
Mailing Address - Country:US
Mailing Address - Phone:770-792-0010
Mailing Address - Fax:
Practice Address - Street 1:2745 SANDY PLAINS RD STE 134
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30066-4327
Practice Address - Country:US
Practice Address - Phone:770-792-0010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2011-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR006794111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA35ZCJTLMedicare UPIN