Provider Demographics
NPI:1568139954
Name:TILLMAN, KIA S (CSFA)
Entity Type:Individual
Prefix:
First Name:KIA
Middle Name:S
Last Name:TILLMAN
Suffix:
Gender:F
Credentials:CSFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1804 E CURTIS ST
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33610-6061
Mailing Address - Country:US
Mailing Address - Phone:513-331-1801
Mailing Address - Fax:
Practice Address - Street 1:11375 CORTEZ BLVD
Practice Address - Street 2:
Practice Address - City:BROOKSVILLE
Practice Address - State:FL
Practice Address - Zip Code:34613-5409
Practice Address - Country:US
Practice Address - Phone:352-596-6632
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-24
Last Update Date:2021-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL156F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156F00000XEye and Vision Services ProvidersTechnician/Technologist