Healthcare Provider Details

I. General information

NPI: 1144475203
Provider Name (Legal Business Name): KAREN TILLER FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/17/2008
Last Update Date: 06/07/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7200 S INGLESIDE AVE
CHICAGO IL
60619-1254
US

IV. Provider business mailing address

7200 S INGLESIDE AVE
CHICAGO IL
60619-1254
US

V. Phone/Fax

Practice location:
  • Phone: 773-324-6942
  • Fax: 773-324-8450
Mailing address:
  • Phone: 773-324-6942
  • Fax: 773-324-8450

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209-000953
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: