Provider Demographics
NPI:1235842451
Name:TILLINGHAST, MARIA
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:
Last Name:TILLINGHAST
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 1:569 APACHE TRL
Mailing Address - Street 2:
Mailing Address - City:CHINA SPRING
Mailing Address - State:TX
Mailing Address - Zip Code:76633-2831
Mailing Address - Country:US
Mailing Address - Phone:719-358-3673
Mailing Address - Fax:
Practice Address - Street 1:569 APACHE TRL
Practice Address - Street 2:
Practice Address - City:CHINA SPRING
Practice Address - State:TX
Practice Address - Zip Code:76633-2831
Practice Address - Country:US
Practice Address - Phone:719-358-3673
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-03
Last Update Date:2023-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX568889163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant