Provider Demographics
NPI:1396621108
Name:PHILLIPS, TINA RENEE
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:RENEE
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4111 HIGHWAY 54
Mailing Address - Street 2:
Mailing Address - City:SENOIA
Mailing Address - State:GA
Mailing Address - Zip Code:30276-2625
Mailing Address - Country:US
Mailing Address - Phone:770-238-6370
Mailing Address - Fax:770-238-6370
Practice Address - Street 1:4111 HIGHWAY 54
Practice Address - Street 2:
Practice Address - City:SENOIA
Practice Address - State:GA
Practice Address - Zip Code:30276-2625
Practice Address - Country:US
Practice Address - Phone:770-238-6370
Practice Address - Fax:770-238-6370
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-15
Last Update Date:2025-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN276096163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse