Provider Demographics
NPI:1144255894
Name:PHILLIPS, JANENE R (RN, FNP)
Entity type:Individual
Prefix:
First Name:JANENE
Middle Name:R
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:RN, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:690 GUZZI LN STE C
Mailing Address - Street 2:
Mailing Address - City:SONORA
Mailing Address - State:CA
Mailing Address - Zip Code:95370-5292
Mailing Address - Country:US
Mailing Address - Phone:209-233-0333
Mailing Address - Fax:209-533-0782
Practice Address - Street 1:690 GUZZI LN STE C
Practice Address - Street 2:
Practice Address - City:SONORA
Practice Address - State:CA
Practice Address - Zip Code:95370-5292
Practice Address - Country:US
Practice Address - Phone:209-233-0333
Practice Address - Fax:209-533-0782
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2016-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9620363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0055890Medicaid
CAGR0055890Medicaid