Healthcare Provider Details

I. General information

NPI: 1528445624
Provider Name (Legal Business Name): TAMMIE L. TILLMAN FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2015
Last Update Date: 10/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3502 WEST NORTSIDE DRIVE
JACKSON MS
39213
US

IV. Provider business mailing address

3502 WEST NORTSIDE DRIVE
JACKSON MS
39213
US

V. Phone/Fax

Practice location:
  • Phone: 601-362-5321
  • Fax: 601-364-5159
Mailing address:
  • Phone: 601-362-5321
  • Fax: 601-364-5159

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberR877379
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: