Provider Demographics
NPI:1205391711
Name:TILLEY, MELANIE DIANE (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:DIANE
Last Name:TILLEY
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2609 MEDICAL OFFICE PL
Mailing Address - Street 2:
Mailing Address - City:GOLDSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27534-9428
Mailing Address - Country:US
Mailing Address - Phone:919-734-1779
Mailing Address - Fax:
Practice Address - Street 1:2609 MEDICAL OFFICE PL
Practice Address - Street 2:
Practice Address - City:GOLDSBORO
Practice Address - State:NC
Practice Address - Zip Code:27534-9428
Practice Address - Country:US
Practice Address - Phone:919-734-1779
Practice Address - Fax:919-734-7570
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-08
Last Update Date:2021-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCTILL-HCY5ZI363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1205391711OtherNPI