Healthcare Provider Details

I. General information

NPI: 1336058890
Provider Name (Legal Business Name): BIANCA D TILLERY LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/02/2026
Last Update Date: 09/02/2026
Certification Date: 09/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6029 WALNUT GROVE RD STE 209
MEMPHIS TN
38120-2112
US

IV. Provider business mailing address

6029 WALNUT GROVE RD STE 209
MEMPHIS TN
38120-2112
US

V. Phone/Fax

Practice location:
  • Phone: 901-681-0778
  • Fax: 901-821-9987
Mailing address:
  • Phone: 901-681-0778
  • Fax: 901-821-9987

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number104394
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: