Provider Demographics
NPI:1114799970
Name:TILLMAN, CONNAITRE SHANTE
Entity Type:Individual
Prefix:
First Name:CONNAITRE
Middle Name:SHANTE
Last Name:TILLMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2409 CHANDLER AVE UNIT 2
Mailing Address - Street 2:
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93065-1955
Mailing Address - Country:US
Mailing Address - Phone:720-905-6298
Mailing Address - Fax:
Practice Address - Street 1:2409 CHANDLER AVE UNIT 2
Practice Address - Street 2:
Practice Address - City:SIMI VALLEY
Practice Address - State:CA
Practice Address - Zip Code:93065-1955
Practice Address - Country:US
Practice Address - Phone:720-905-6298
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-25
Last Update Date:2023-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374J00000XNursing Service Related ProvidersDoulaGroup - Single Specialty