Healthcare Provider Details

I. General information

NPI: 1992852123
Provider Name (Legal Business Name): PATRICE VIVIEN TILLMAN RN,MSN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/03/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

175 GWINNETT DR
LAWRENCEVILLE GA
30045-8444
US

IV. Provider business mailing address

175 GWINNETT DR
LAWRENCEVILLE GA
30045-8444
US

V. Phone/Fax

Practice location:
  • Phone: 770-339-5000
  • Fax: 770-822-1698
Mailing address:
  • Phone: 770-339-5000
  • Fax: 770-822-1698

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License NumberRN058224
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: