Healthcare Provider Details

I. General information

NPI: 1467063073
Provider Name (Legal Business Name): KELLY TILLMAN CALDWELL PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KELLY LYNN TILLMAN

II. Dates (important events)

Enumeration Date: 08/17/2020
Last Update Date: 07/06/2022
Certification Date: 07/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

575 STANTON RD
MOBILE AL
36617-2344
US

IV. Provider business mailing address

PO BOX 746450
ATLANTA GA
30374-6450
US

V. Phone/Fax

Practice location:
  • Phone: 251-471-7207
  • Fax: 251-471-7468
Mailing address:
  • Phone: 251-434-3626
  • Fax: 251-445-2464

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1849
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: