Provider Demographics
NPI:1497380711
Name:TILLMAN, JANICE JOHNSON (FNP-BC)
Entity Type:Individual
Prefix:
First Name:JANICE
Middle Name:JOHNSON
Last Name:TILLMAN
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2050 RUSSELL J TILLMAN RD
Mailing Address - Street 2:
Mailing Address - City:EDWARDS
Mailing Address - State:MS
Mailing Address - Zip Code:39066-9101
Mailing Address - Country:US
Mailing Address - Phone:601-988-3728
Mailing Address - Fax:
Practice Address - Street 1:5429 ROBINSON ROAD EXT
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39204-4138
Practice Address - Country:US
Practice Address - Phone:601-914-0163
Practice Address - Fax:601-914-0170
Is Sole Proprietor?:No
Enumeration Date:2020-03-06
Last Update Date:2021-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS884780163W00000X
MS904041363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse