=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639255722
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LUCY ANNE TILLETT RN, CNS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/31/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2724 NE DUNCKLEY ST
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97212-1644
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-869-1627
-----------------------------------------------------
Fax | 503-488-5852
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2724 NE DUNCKLEY ST
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97212-1644
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-869-1627
-----------------------------------------------------
Fax | 503-488-5852
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 364SA2200X
-----------------------------------------------------
Taxonomy Name | Adult Health Clinical Nurse Specialist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------