Provider Demographics
NPI:1568829398
Name:TILLMON, AMY
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:TILLMON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:M
Other - Last Name:JENNINGS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 142
Mailing Address - Street 2:20 MCCLELLAN ST
Mailing Address - City:PORT BYRON
Mailing Address - State:NY
Mailing Address - Zip Code:13140
Mailing Address - Country:US
Mailing Address - Phone:315-209-3771
Mailing Address - Fax:
Practice Address - Street 1:20 MCCLELLAN ST
Practice Address - Street 2:
Practice Address - City:PORT BYRON
Practice Address - State:NY
Practice Address - Zip Code:13140-7706
Practice Address - Country:US
Practice Address - Phone:315-209-3771
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-25
Last Update Date:2016-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY298083164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse