Provider Demographics
NPI:1972920437
Name:ANDERSON, PHYLLIS (RN)
Entity type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:PHYLLIS
Other - Middle Name:
Other - Last Name:O'CONNELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:3550 GOODWYN RD
Mailing Address - Street 2:
Mailing Address - City:POWHATAN
Mailing Address - State:VA
Mailing Address - Zip Code:23139-5810
Mailing Address - Country:US
Mailing Address - Phone:804-598-3916
Mailing Address - Fax:
Practice Address - Street 1:12124 HIGH TECH AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32817-8373
Practice Address - Country:US
Practice Address - Phone:800-300-5132
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-23
Last Update Date:2014-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001104850163WC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine