Provider Demographics
NPI:1720887037
Name:PHILLIPS, DESIRAI
Entity type:Individual
Prefix:
First Name:DESIRAI
Middle Name:
Last Name:PHILLIPS
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7501 SUNRISE BLVD
Mailing Address - Street 2:
Mailing Address - City:CITRUS HEIGHTS
Mailing Address - State:CA
Mailing Address - Zip Code:95610-3059
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7501 SUNRISE BLVD
Practice Address - Street 2:
Practice Address - City:CITRUS HEIGHTS
Practice Address - State:CA
Practice Address - Zip Code:95610-3059
Practice Address - Country:US
Practice Address - Phone:916-296-5310
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-10
Last Update Date:2025-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker