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General NPI Number Information
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NPI Number | 1578112959
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Entity Type | Individual
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Provider Name | KELLI MARIE BAKER TILLMAN FNP-C
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Gender | Female
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Dates
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Enumeration Date | 09/08/2019
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Last Update Date | 01/08/2021
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Provider Practice Location Address
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Address Line | 1411 GREENWAY CT
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City | SANFORD
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State | NC
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Zip | 27330-6954
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Country | US
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Telephone | 919-292-1878
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Fax |
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Provider Business Mailing Address
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Address Line | 1197 S PLANK RD
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City | SANFORD
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State | NC
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Zip | 27330-8620
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Country | US
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Telephone | 919-356-2735
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number | F06191243
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License Number State | NC
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