Provider Demographics
NPI:1649245960
Name:PHILLIPS, JONNIE S (NURSE PRACTITIONER)
Entity type:Individual
Prefix:
First Name:JONNIE
Middle Name:S
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3747 W FORK RD
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45247-7548
Mailing Address - Country:US
Mailing Address - Phone:513-961-4335
Mailing Address - Fax:513-961-4227
Practice Address - Street 1:3747 W FORK RD
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45247-7548
Practice Address - Country:US
Practice Address - Phone:513-961-4335
Practice Address - Fax:513-961-4227
Is Sole Proprietor?:No
Enumeration Date:2006-02-21
Last Update Date:2024-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH08008363L00000X
OHAPRN.CNP.08008363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2535993Medicaid
KY7100056850Medicaid
KY78014164Medicaid
P00316324OtherRAIL ROAD MEDICARE
IN200517900Medicaid
IN200517900AMedicaid
IN200517900AMedicaid
OH2535993Medicaid