Healthcare Provider Details

I. General information

NPI: 1326330432
Provider Name (Legal Business Name): MONIQUE TAKEISHA TILLERY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MONIQUE TAKEISHA TILLERY RN

II. Dates (important events)

Enumeration Date: 05/08/2011
Last Update Date: 05/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2250 HICKORY RD STE 240
PLYMOUTH MEETING PA
19462-2225
US

IV. Provider business mailing address

4222 RED HAVEN RD
PIKESVILLE MD
21208-5853
US

V. Phone/Fax

Practice location:
  • Phone: 800-879-4471
  • Fax: 610-825-1604
Mailing address:
  • Phone: 410-484-7106
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR164341
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: