Provider Demographics
NPI:1770681595
Name:PHELPS, PHYLLIS L (ARNP)
Entity type:Individual
Prefix:MS
First Name:PHYLLIS
Middle Name:L
Last Name:PHELPS
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:PHYLLIS
Other - Middle Name:
Other - Last Name:PATTEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ARNP
Mailing Address - Street 1:2315 W JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32505-7552
Mailing Address - Country:US
Mailing Address - Phone:850-436-4630
Mailing Address - Fax:850-436-2095
Practice Address - Street 1:2315 W JACKSON ST
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32505-7552
Practice Address - Country:US
Practice Address - Phone:850-436-4630
Practice Address - Fax:850-436-2095
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2025-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNCNP 4348363LF0000X
FL9232460363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL307400500Medicaid
Q05193Medicare UPIN