Provider Demographics
NPI:1073582763
Name:TILLEY, LESA RICE (CRNA)
Entity Type:Individual
Prefix:
First Name:LESA
Middle Name:RICE
Last Name:TILLEY
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:416 BRIDGEWATER CIR
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:LA
Mailing Address - Zip Code:71006-8807
Mailing Address - Country:US
Mailing Address - Phone:318-525-8688
Mailing Address - Fax:
Practice Address - Street 1:403 MAGAZINE CT
Practice Address - Street 2:
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71111-6263
Practice Address - Country:US
Practice Address - Phone:228-365-7568
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-15
Last Update Date:2024-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX628349163W00000X
LA139177163W00000X
LAAP07128163W00000X, 367500000X
INRN139177367500000X
TXAP116957367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX320043YK6UMedicare PIN