Provider Demographics
NPI:1275886103
Name:TILLMAN, KENOSHA LATRICE (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:MISS
First Name:KENOSHA
Middle Name:LATRICE
Last Name:TILLMAN
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 1:5220 ROSEWOOD PL
Mailing Address - Street 2:
Mailing Address - City:FAIRBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30213-5113
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5220 ROSEWOOD PL
Practice Address - Street 2:
Practice Address - City:FAIRBURN
Practice Address - State:GA
Practice Address - Zip Code:30213-5113
Practice Address - Country:US
Practice Address - Phone:901-277-7086
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-16
Last Update Date:2022-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAGAA-NP000960363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health