Provider Demographics
NPI:1609409432
Name:TILLINGHAST, AZALIAH HANNAH (FNP-BC)
Entity Type:Individual
Prefix:
First Name:AZALIAH
Middle Name:HANNAH
Last Name:TILLINGHAST
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:167 MIDDLE ROAD
Mailing Address - Street 2:
Mailing Address - City:GRANITEVILLE
Mailing Address - State:VT
Mailing Address - Zip Code:05654
Mailing Address - Country:US
Mailing Address - Phone:802-522-4291
Mailing Address - Fax:
Practice Address - Street 1:2418 AIRPORT RD
Practice Address - Street 2:
Practice Address - City:BARRE
Practice Address - State:VT
Practice Address - Zip Code:05641-8702
Practice Address - Country:US
Practice Address - Phone:802-224-3200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-20
Last Update Date:2020-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT101.0134487363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily