Provider Demographics
NPI:1861698342
Name:PHILLIPS, KASSANDRA JANE (DO)
Entity type:Individual
Prefix:DR
First Name:KASSANDRA
Middle Name:JANE
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2937 FOX CHASE LN
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23112-4400
Mailing Address - Country:US
Mailing Address - Phone:804-372-3473
Mailing Address - Fax:
Practice Address - Street 1:2937 FOX CHASE LN
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23112-4400
Practice Address - Country:US
Practice Address - Phone:804-372-3473
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-22
Last Update Date:2020-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV22712080I0007X
VA0102206067208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080I0007XAllopathic & Osteopathic PhysiciansPediatricsClinical & Laboratory Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810015268Medicaid