Provider Demographics
NPI:1578112959
Name:TILLMAN, KELLI MARIE BAKER (FNP-C)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:MARIE BAKER
Last Name:TILLMAN
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1197 S PLANK RD
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:NC
Mailing Address - Zip Code:27330-8620
Mailing Address - Country:US
Mailing Address - Phone:919-356-2735
Mailing Address - Fax:
Practice Address - Street 1:1411 GREENWAY CT
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:NC
Practice Address - Zip Code:27330-6954
Practice Address - Country:US
Practice Address - Phone:919-292-1878
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-08
Last Update Date:2021-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCF06191243363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner