Provider Demographics
NPI:1669630844
Name:TILLER, BEATRICE JOY
Entity Type:Individual
Prefix:
First Name:BEATRICE
Middle Name:JOY
Last Name:TILLER
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 1:6905 RICHARDSON RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32209-1315
Mailing Address - Country:US
Mailing Address - Phone:904-527-8340
Mailing Address - Fax:
Practice Address - Street 1:6905 RICHARDSON RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32209-1315
Practice Address - Country:US
Practice Address - Phone:904-527-8340
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-24
Last Update Date:2008-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPN5163272164W00000X
172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
No172V00000XOther Service ProvidersCommunity Health Worker