Healthcare Provider Details

I. General information

NPI: 1225787740
Provider Name (Legal Business Name): HALEY TILLMAN FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: HALEY WEAVER

II. Dates (important events)

Enumeration Date: 03/22/2022
Last Update Date: 10/09/2024
Certification Date: 10/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1720A MEDICAL PARK DR STE 150
BILOXI MS
39532-2135
US

IV. Provider business mailing address

2101 HIGHWAY 90
GAUTIER MS
39553-5340
US

V. Phone/Fax

Practice location:
  • Phone: 228-392-7429
  • Fax: 228-396-3830
Mailing address:
  • Phone: 228-497-7576
  • Fax: 228-497-8869

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number905171
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: