MEDICARE: MS. CHENETTE TILLMAN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171M00000X	Case Manager/Care Coordinator

General Provider Information

NPI Number	:	1710636584
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. CHENETTE TILLMAN

Provider Business Mailing Address
First Line	:	4215 N 13TH ST
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33603-4413
Country	:	US
Telephone Number	:	813-528-2256
Fax Number	:

Provider Business Practice Location Address
First Line	:	4215 N 13TH ST
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33603-4413
Country	:	US
Telephone Number	:	813-528-2256
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/21/2022
Last Update Date	:	03/21/2022

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