Provider Demographics
NPI:1679695993
Name:TILLMAN, MELODY L (NP)
Entity Type:Individual
Prefix:
First Name:MELODY
Middle Name:L
Last Name:TILLMAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:157 N BELLS ST
Mailing Address - Street 2:
Mailing Address - City:ALAMO
Mailing Address - State:TN
Mailing Address - Zip Code:38001-1767
Mailing Address - Country:US
Mailing Address - Phone:731-696-5551
Mailing Address - Fax:731-696-2802
Practice Address - Street 1:157 N BELLS ST
Practice Address - Street 2:
Practice Address - City:ALAMO
Practice Address - State:TN
Practice Address - Zip Code:38001-1767
Practice Address - Country:US
Practice Address - Phone:731-696-5551
Practice Address - Fax:731-696-2802
Is Sole Proprietor?:No
Enumeration Date:2007-04-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNRN0000037848363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner