Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 224P00000X | Prosthetist | C5804 | NC |
NPI | 1215398946 |
---|---|
Provider Name | Charlene Phillips |
First Address | Fayetteville, NC 28303 |
Second Address | Fayetteville, NC 28303-6014 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 08/03/2016 |
Last Update Date | 08/03/2016 |