Provider Demographics
NPI:1295718112
Name:PHILLIPS, DOROTHY (APRN)
Entity type:Individual
Prefix:
First Name:DOROTHY
Middle Name:
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:168 PROSPECT ST
Mailing Address - Street 2:
Mailing Address - City:WILLIMANTIC
Mailing Address - State:CT
Mailing Address - Zip Code:06226-2502
Mailing Address - Country:US
Mailing Address - Phone:860-456-1913
Mailing Address - Fax:
Practice Address - Street 1:168 PROSPECT ST
Practice Address - Street 2:
Practice Address - City:WILLIMANTIC
Practice Address - State:CT
Practice Address - Zip Code:06226-2502
Practice Address - Country:US
Practice Address - Phone:860-456-1913
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-23
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000975363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MP0508828OtherDRUG ENFORCEMENT ADMINISTRATION, US DEPARTMENT OF JUSTICE