Healthcare Provider Details

I. General information

NPI: 1316992795
Provider Name (Legal Business Name): MS. DEBBIE A TILLOTSON
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/23/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3515 BROADWAY AVE
GREAT BEND KS
67530-3633
US

IV. Provider business mailing address

3515 BROADWAY AVE
GREAT BEND KS
67530-3633
US

V. Phone/Fax

Practice location:
  • Phone: 620-786-6268
  • Fax:
Mailing address:
  • Phone: 620-786-6268
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number199
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: