Provider Demographics
NPI:1518396985
Name:TILLMAN, LESLIE (CRNP)
Entity Type:Individual
Prefix:MS
First Name:LESLIE
Middle Name:
Last Name:TILLMAN
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 744785
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-4785
Mailing Address - Country:US
Mailing Address - Phone:202-476-5000
Mailing Address - Fax:
Practice Address - Street 1:9850 KEY WEST AVE
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20850-3960
Practice Address - Country:US
Practice Address - Phone:301-765-5400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-06
Last Update Date:2021-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDAC001267363LP0200X
VA0024172978363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Single Specialty