Provider Demographics
NPI:1093825010
Name:TILLERY, TRACI M (FNP)
Entity Type:Individual
Prefix:
First Name:TRACI
Middle Name:M
Last Name:TILLERY
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 E 2ND AVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30161-3224
Mailing Address - Country:US
Mailing Address - Phone:706-509-3278
Mailing Address - Fax:706-509-4608
Practice Address - Street 1:304 TURNER MCCALL BLVD SW
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30165-5621
Practice Address - Country:US
Practice Address - Phone:706-509-5000
Practice Address - Fax:706-509-4608
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA106991363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAPENDINGMedicaid
GAPENDINGMedicare UPIN
GAPENDINGMedicaid