Provider Demographics
NPI:1922563030
Name:PHILLIP, ANDELL Y
Entity type:Individual
Prefix:
First Name:ANDELL
Middle Name:Y
Last Name:PHILLIP
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8810 SW HIGHWAY 200 UNIT 124
Mailing Address - Street 2:
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34481-7822
Mailing Address - Country:US
Mailing Address - Phone:352-502-4923
Mailing Address - Fax:
Practice Address - Street 1:1540 INTERNATIONAL PKWY STE 2000
Practice Address - Street 2:
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-5096
Practice Address - Country:US
Practice Address - Phone:352-502-4923
Practice Address - Fax:352-504-0241
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-02
Last Update Date:2023-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL166697376K00000X
FL239577376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
No376K00000XNursing Service Related ProvidersNurse's Aide