Provider Demographics
NPI:1043986490
Name:TILLMAN, ANTOINETTE MICHELE (NP)
Entity Type:Individual
Prefix:
First Name:ANTOINETTE
Middle Name:MICHELE
Last Name:TILLMAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3722 DANCE MILL RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:MD
Mailing Address - Zip Code:21131-2120
Mailing Address - Country:US
Mailing Address - Phone:410-591-3772
Mailing Address - Fax:
Practice Address - Street 1:6535 N CHARLES ST STE 500
Practice Address - Street 2:
Practice Address - City:TOWSON
Practice Address - State:MD
Practice Address - Zip Code:21204-5832
Practice Address - Country:US
Practice Address - Phone:410-825-5454
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-17
Last Update Date:2021-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR080373363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily