Healthcare Provider Details

I. General information

NPI: 1669719159
Provider Name (Legal Business Name): MRS. KRISTI DARIA TILL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KRISTI DARIA TILL RN

II. Dates (important events)

Enumeration Date: 01/03/2013
Last Update Date: 01/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1015 WILLAMETTE ST
EUGENE OR
97401-3113
US

IV. Provider business mailing address

PO BOX 432
VENETA OR
97487-0432
US

V. Phone/Fax

Practice location:
  • Phone: 541-935-0408
  • Fax: 541-935-6270
Mailing address:
  • Phone: 541-935-0408
  • Fax: 541-935-6270

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number096003255RN
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: