Provider Demographics
NPI:1407281165
Name:TILLMAN, KEYONNA (CD)
Entity Type:Individual
Prefix:
First Name:KEYONNA
Middle Name:
Last Name:TILLMAN
Suffix:
Gender:F
Credentials:CD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1023 CRESTMARK BLVD
Mailing Address - Street 2:
Mailing Address - City:LITHIA SPRINGS
Mailing Address - State:GA
Mailing Address - Zip Code:30122-2645
Mailing Address - Country:US
Mailing Address - Phone:470-234-7612
Mailing Address - Fax:
Practice Address - Street 1:1023 CRESTMARK BLVD
Practice Address - Street 2:
Practice Address - City:LITHIA SPRINGS
Practice Address - State:GA
Practice Address - Zip Code:30122-2645
Practice Address - Country:US
Practice Address - Phone:470-234-7612
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-12
Last Update Date:2013-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator