Healthcare Provider Details

I. General information

NPI: 1104944420
Provider Name (Legal Business Name): KIMBERLY HAGEN TILLAR R.N.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2021 SANTA MONICA BLVD SUIT 400E
SANTA MONICA CA
90404-2208
US

IV. Provider business mailing address

7819 BLERIOT AVE
LOS ANGELES CA
90045-2904
US

V. Phone/Fax

Practice location:
  • Phone: 310-453-5654
  • Fax:
Mailing address:
  • Phone: 310-649-3239
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WX0200X
TaxonomyOncology Registered Nurse
License Number375548
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: