Healthcare Provider Details

I. General information

NPI: 1104411230
Provider Name (Legal Business Name): KELSEY LYN TILLMAN DNP, APRN, FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/01/2021
Last Update Date: 03/20/2026
Certification Date: 03/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 MARKET ST STE 300
FULTON MO
65251-2808
US

IV. Provider business mailing address

500 MARKET ST STE 300
FULTON MO
65251-2808
US

V. Phone/Fax

Practice location:
  • Phone: 573-200-6078
  • Fax: 833-817-7109
Mailing address:
  • Phone: 573-200-6078
  • Fax: 833-817-7109

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number2015001994
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2021007044
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: