Individual
FANNIE PHILLIPS
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
LMT
Contact information
Practice address
1748 NW FAIRVIEW DR, GRESHAM, OR 97030-3842
(503) 492-3910
Mailing address
1748 NW FAIRVIEW DR, GRESHAM, OR 97030-3842
(503) 492-3910
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
Primary
15141
OR
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0000000
HMO
OR
01
—
225700000X
LMT
OR
Enumeration date
10/25/2016
Last updated
10/25/2016
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