Provider Demographics
NPI:1912795055
Name:PHILLIPS, DESTINY
Entity type:Individual
Prefix:
First Name:DESTINY
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 1:410 PINE HILL RD SE
Mailing Address - Street 2:
Mailing Address - City:RYDAL
Mailing Address - State:GA
Mailing Address - Zip Code:30171-1736
Mailing Address - Country:US
Mailing Address - Phone:678-654-9610
Mailing Address - Fax:
Practice Address - Street 1:715 E 2ND AVE SW
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30161-6148
Practice Address - Country:US
Practice Address - Phone:706-291-9898
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-29
Last Update Date:2025-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN295096363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily