Provider Demographics
NPI:1003476383
Name:TILLMON, KEONA JEWEL
Entity Type:Individual
Prefix:
First Name:KEONA
Middle Name:JEWEL
Last Name:TILLMON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3920 W CHARLESTON BLVD STE O
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89102-1633
Mailing Address - Country:US
Mailing Address - Phone:702-784-5541
Mailing Address - Fax:702-915-7664
Practice Address - Street 1:3920 W CHARLESTON BLVD STE O
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89102-1633
Practice Address - Country:US
Practice Address - Phone:702-784-5541
Practice Address - Fax:702-915-7664
Is Sole Proprietor?:No
Enumeration Date:2019-06-18
Last Update Date:2019-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other