Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LF0000X | Nurse Practitioner - Family Medicine | RN260210 | GA |
NPI | 1003300757 |
---|---|
Provider Name | Ms. Moensania Carisa Phillips |
First Address | Atlanta, GA 30340 |
Second Address | Atlanta, GA 30306-4565 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 17/06/2018 |
Last Update Date | 12/11/2020 |