Provider Demographics
NPI:1700385242
Name:TILLMAN, CARRIE LOUISE (REGISTERED NURSE)
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:LOUISE
Last Name:TILLMAN
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16215 WOODBRIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:HARVEY
Mailing Address - State:IL
Mailing Address - Zip Code:60426-5946
Mailing Address - Country:US
Mailing Address - Phone:708-203-1755
Mailing Address - Fax:
Practice Address - Street 1:16215 WOODBRIDGE AVE
Practice Address - Street 2:
Practice Address - City:HARVEY
Practice Address - State:IL
Practice Address - Zip Code:60426-5946
Practice Address - Country:US
Practice Address - Phone:708-203-1755
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-11
Last Update Date:2018-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041356509163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL163W0000XMedicaid