Provider Demographics
NPI:1649339367
Name:PHILLIPS-GROSSMAN, MARILYN L (FNP)
Entity type:Individual
Prefix:
First Name:MARILYN
Middle Name:L
Last Name:PHILLIPS-GROSSMAN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:159 EXECUTIVE DR
Mailing Address - Street 2:SUITE C
Mailing Address - City:DANVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24541-4160
Mailing Address - Country:US
Mailing Address - Phone:434-792-0830
Mailing Address - Fax:434-792-0468
Practice Address - Street 1:159 EXECUTIVE DR
Practice Address - Street 2:SUITE C
Practice Address - City:DANVILLE
Practice Address - State:VA
Practice Address - Zip Code:24541-4160
Practice Address - Country:US
Practice Address - Phone:434-792-0830
Practice Address - Fax:434-792-0468
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2023-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA007026D23363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010108586Medicaid
VA010108586Medicaid