=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568080422
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHARI TILLMAN FNP-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/08/2020
-----------------------------------------------------
Last Update Date | 07/30/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 375 S COURTENAY PKWY STE 4
-----------------------------------------------------
City | MERRITT ISLAND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32952-4868
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-544-0757
-----------------------------------------------------
Fax | 321-338-7062
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 375 S COURTENAY PKWY STE 4
-----------------------------------------------------
City | MERRITT ISLAND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32952-4868
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-544-0757
-----------------------------------------------------
Fax | 321-338-7062
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 11007581
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------