Provider Demographics
NPI:1083191076
Name:TILLER, JOHNITA (APRN)
Entity Type:Individual
Prefix:
First Name:JOHNITA
Middle Name:
Last Name:TILLER
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:JOHNITA
Other - Middle Name:
Other - Last Name:HENDRICKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:303 LIBORIO DR
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:DE
Mailing Address - Zip Code:19709-3112
Mailing Address - Country:US
Mailing Address - Phone:302-563-4678
Mailing Address - Fax:
Practice Address - Street 1:1 CHESTNUT HILL PLZ
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19713-2701
Practice Address - Country:US
Practice Address - Phone:302-266-0960
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-23
Last Update Date:2021-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DELG-0001146363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily