Provider Demographics
NPI:1548872468
Name:WOOD, PHYLLIS KELLY
Entity type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:KELLY
Last Name:WOOD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 S 8TH ST
Mailing Address - Street 2:
Mailing Address - City:GRIFFIN
Mailing Address - State:GA
Mailing Address - Zip Code:30224-4213
Mailing Address - Country:US
Mailing Address - Phone:770-467-6314
Mailing Address - Fax:770-467-6324
Practice Address - Street 1:601 S 8TH ST
Practice Address - Street 2:
Practice Address - City:GRIFFIN
Practice Address - State:GA
Practice Address - Zip Code:30224-4213
Practice Address - Country:US
Practice Address - Phone:770-467-6314
Practice Address - Fax:770-467-6324
Is Sole Proprietor?:No
Enumeration Date:2020-08-21
Last Update Date:2021-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN216745363LA2200X, 363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health