Healthcare Provider Details

I. General information

NPI: 1386938249
Provider Name (Legal Business Name): JACQUELINE ANTOINETTE TILLER MSN,FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/07/2011
Last Update Date: 06/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

810 NEW BURTON RD SUITE #1
DOVER DE
19904-5488
US

IV. Provider business mailing address

810 NEW BURTON RD SUITE #1
DOVER DE
19904-5488
US

V. Phone/Fax

Practice location:
  • Phone: 302-744-9310
  • Fax: 302-744-9312
Mailing address:
  • Phone: 302-744-9310
  • Fax: 302-744-9312

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberLG-0000558
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: