Provider Demographics
NPI:1003693094
Name:TATE, JILLIAN NICOLE (FNP-C)
Entity Type:Individual
Prefix:
First Name:JILLIAN
Middle Name:NICOLE
Last Name:TATE
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6716 COMMONWEALTH RD
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:TX
Mailing Address - Zip Code:79706-3177
Mailing Address - Country:US
Mailing Address - Phone:405-371-5938
Mailing Address - Fax:
Practice Address - Street 1:821 JEFFEE DR
Practice Address - Street 2:
Practice Address - City:KERMIT
Practice Address - State:TX
Practice Address - Zip Code:79745-4696
Practice Address - Country:US
Practice Address - Phone:432-586-8299
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-12
Last Update Date:2023-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1135946363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily