Provider Demographics
NPI:1659738938
Name:TILLMAN, ELAN
Entity Type:Individual
Prefix:MS
First Name:ELAN
Middle Name:
Last Name:TILLMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2407 N 41ST ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53210-2933
Mailing Address - Country:US
Mailing Address - Phone:414-702-6771
Mailing Address - Fax:
Practice Address - Street 1:2407 N 41ST ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53210-2933
Practice Address - Country:US
Practice Address - Phone:414-702-6771
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-18
Last Update Date:2016-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care