Healthcare Provider Details

I. General information

NPI: 1629824719
Provider Name (Legal Business Name): LAUREN ANNE TILLERY PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: LAUREN LAVERY PA

II. Dates (important events)

Enumeration Date: 04/29/2024
Last Update Date: 09/18/2026
Certification Date: 09/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7440 W FRONTAGE RD
MERRIAM KS
66203-4670
US

IV. Provider business mailing address

4508 TOMAHAWK RD
PRAIRIE VILLAGE KS
66208-2842
US

V. Phone/Fax

Practice location:
  • Phone: 913-236-6455
  • Fax: 913-236-6678
Mailing address:
  • Phone: 913-972-6627
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: