Provider Demographics
NPI:1972731107
Name:EATON, PHYLLIS MARIE (PHD, RN, PMHCNS-BC)
Entity type:Individual
Prefix:DR
First Name:PHYLLIS
Middle Name:MARIE
Last Name:EATON
Suffix:
Gender:F
Credentials:PHD, RN, PMHCNS-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 INDEPENDENCE CIR STE 3D
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23455-6405
Mailing Address - Country:US
Mailing Address - Phone:757-473-8533
Mailing Address - Fax:757-456-0616
Practice Address - Street 1:700 INDEPENDENCE CIR STE 3D
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23455-6405
Practice Address - Country:US
Practice Address - Phone:757-473-8533
Practice Address - Fax:757-456-0616
Is Sole Proprietor?:No
Enumeration Date:2009-06-25
Last Update Date:2009-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001128454163W00000X
VA0015000876364SP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Adult
No163W00000XNursing Service ProvidersRegistered Nurse