Provider Demographics
NPI:1639330038
Name:TILLMAN, SUSAN ELIZABETH (CPNP)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:ELIZABETH
Last Name:TILLMAN
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20925 PROFESSIONAL PLZ
Mailing Address - Street 2:SUITE 340
Mailing Address - City:ASHBURN
Mailing Address - State:VA
Mailing Address - Zip Code:20147-3403
Mailing Address - Country:US
Mailing Address - Phone:703-723-8900
Mailing Address - Fax:
Practice Address - Street 1:20925 PROFESSIONAL PLZ
Practice Address - Street 2:SUITE 340
Practice Address - City:ASHBURN
Practice Address - State:VA
Practice Address - Zip Code:20147-3403
Practice Address - Country:US
Practice Address - Phone:703-723-8900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-19
Last Update Date:2013-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024151999363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA31-1739955OtherTIN