Provider Demographics
NPI:1619869757
Name:PHILLIPS, MARY ADDISON
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:ADDISON
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:MARY
Other - Middle Name:ADDISON
Other - Last Name:WADSWORTH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:212 SPRINGWOOD DR
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72211-5731
Mailing Address - Country:US
Mailing Address - Phone:901-488-9311
Mailing Address - Fax:
Practice Address - Street 1:4301 W MARKHAM ST
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-7101
Practice Address - Country:US
Practice Address - Phone:501-296-1100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-07-15
Last Update Date:2025-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program