Healthcare Provider Details

I. General information

NPI: 1316838204
Provider Name (Legal Business Name): MACY TILLMAN APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2025
Last Update Date: 07/22/2025
Certification Date: 07/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

203 WATSON ST STE 200
PRATT KS
67124-3092
US

IV. Provider business mailing address

PO BOX 308
PRATT KS
67124-0308
US

V. Phone/Fax

Practice location:
  • Phone: 620-672-7422
  • Fax: 855-884-8184
Mailing address:
  • Phone: 620-672-7422
  • Fax: 855-884-8184

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number53-84535-072
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: