Provider Demographics
NPI:1285208389
Name:TILLMAN, DELMENA
Entity Type:Individual
Prefix:
First Name:DELMENA
Middle Name:
Last Name:TILLMAN
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 1:6452 WESTRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:WATAUGA
Mailing Address - State:TX
Mailing Address - Zip Code:76148-1429
Mailing Address - Country:US
Mailing Address - Phone:918-313-0236
Mailing Address - Fax:
Practice Address - Street 1:6452 WESTRIDGE DR
Practice Address - Street 2:
Practice Address - City:WATAUGA
Practice Address - State:TX
Practice Address - Zip Code:76148-1429
Practice Address - Country:US
Practice Address - Phone:918-313-0236
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-14
Last Update Date:2021-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347E00000XTransportation ServicesTransportation Broker