Healthcare Provider Details

I. General information

NPI: 1982141107
Provider Name (Legal Business Name): MEGAN W TILLMAN CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MEGAN L WEAVER CRNP

II. Dates (important events)

Enumeration Date: 01/25/2017
Last Update Date: 01/25/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

287 HEALTHWEST DR
DOTHAN AL
36303-2031
US

IV. Provider business mailing address

287 HEALTHWEST DR
DOTHAN AL
36303-2031
US

V. Phone/Fax

Practice location:
  • Phone: 334-792-9500
  • Fax: 334-793-4804
Mailing address:
  • Phone: 334-792-9500
  • Fax: 334-793-4804

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1-131459
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: