Provider Demographics
NPI:1124588660
Name:TILLACK, CAITLIN L (ANP)
Entity Type:Individual
Prefix:
First Name:CAITLIN
Middle Name:L
Last Name:TILLACK
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 KINGS HWY S
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14617-5504
Mailing Address - Country:US
Mailing Address - Phone:585-922-1900
Mailing Address - Fax:585-922-0636
Practice Address - Street 1:495 N MAIN ST
Practice Address - Street 2:
Practice Address - City:CANANDAIGUA
Practice Address - State:NY
Practice Address - Zip Code:14424-1283
Practice Address - Country:US
Practice Address - Phone:585-393-3515
Practice Address - Fax:585-393-3526
Is Sole Proprietor?:No
Enumeration Date:2019-03-21
Last Update Date:2021-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY309029363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology