Provider Demographics
NPI:1144225954
Name:TILLMAN, JANICE H (FNP)
Entity Type:Individual
Prefix:
First Name:JANICE
Middle Name:H
Last Name:TILLMAN
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:PO BOX 850
Mailing Address - Street 2:
Mailing Address - City:ROGERSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37857-0850
Mailing Address - Country:US
Mailing Address - Phone:423-772-3276
Mailing Address - Fax:423-772-4816
Practice Address - Street 1:152 HIGHWAY 143
Practice Address - Street 2:
Practice Address - City:ROAN MOUNTAIN
Practice Address - State:TN
Practice Address - Zip Code:37687-3002
Practice Address - Country:US
Practice Address - Phone:423-772-3276
Practice Address - Fax:423-772-4816
Is Sole Proprietor?:No
Enumeration Date:2005-06-17
Last Update Date:2014-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN6192363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3343322Medicaid
TN3039321OtherBCBST
3343324Medicare PIN
3343324Medicare ID - Type Unspecified
3703860Medicare PIN
500004754Medicare UPIN
S27682Medicare UPIN
3703865Medicare PIN
TN3343322Medicaid