Healthcare Provider Details

I. General information

NPI: 1124664511
Provider Name (Legal Business Name): TIFFANY LEIGH TILLMAN RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/21/2019
Last Update Date: 11/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4700 MUELLER BRASS RD
COVINGTON TN
38019-3754
US

IV. Provider business mailing address

47 DARLINGTON DR
BRIGHTON TN
38011-2600
US

V. Phone/Fax

Practice location:
  • Phone: 901-476-0235
  • Fax:
Mailing address:
  • Phone: 901-208-1214
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License Number0000192441
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: