Provider Demographics
NPI:1710426259
Name:TILLERY, DIBA (RN, IBCLC)
Entity Type:Individual
Prefix:
First Name:DIBA
Middle Name:
Last Name:TILLERY
Suffix:
Gender:F
Credentials:RN, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9311 N FM 620 RD # 247
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78726-4129
Mailing Address - Country:US
Mailing Address - Phone:512-765-9959
Mailing Address - Fax:888-227-7057
Practice Address - Street 1:301 BRUSHY CREEK RD STE 106
Practice Address - Street 2:
Practice Address - City:CEDAR PARK
Practice Address - State:TX
Practice Address - Zip Code:78613-3151
Practice Address - Country:US
Practice Address - Phone:512-765-9599
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-16
Last Update Date:2021-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL-36079163WL0100X
TX664335163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant