Provider Demographics
NPI:1558666842
Name:TILLMAM, WENDY MARIE (IDC)
Entity Type:Individual
Prefix:
First Name:WENDY
Middle Name:MARIE
Last Name:TILLMAM
Suffix:
Gender:F
Credentials:IDC
Other - Prefix:
Other - First Name:WENDY
Other - Middle Name:MARIE
Other - Last Name:DETTLOFF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:USS NITZE (DDG94)
Mailing Address - Street 2:MEDICAL DEPT
Mailing Address - City:FPO
Mailing Address - State:AE
Mailing Address - Zip Code:09579-1200
Mailing Address - Country:US
Mailing Address - Phone:757-445-6087
Mailing Address - Fax:
Practice Address - Street 1:USS NITZE (DDG94)
Practice Address - Street 2:MEDICAL DEPT
Practice Address - City:FPO
Practice Address - State:AE
Practice Address - Zip Code:09579-1200
Practice Address - Country:US
Practice Address - Phone:757-445-6087
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-18
Last Update Date:2011-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman