Provider Demographics
NPI:1720359516
Name:TILLERY, MOYO BUNMI (PT, DPT, FAAOMPT)
Entity Type:Individual
Prefix:DR
First Name:MOYO
Middle Name:BUNMI
Last Name:TILLERY
Suffix:
Gender:F
Credentials:PT, DPT, FAAOMPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1702 OWEN DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28304-3419
Mailing Address - Country:US
Mailing Address - Phone:910-323-3184
Mailing Address - Fax:910-323-9577
Practice Address - Street 1:1702 OWEN DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-3419
Practice Address - Country:US
Practice Address - Phone:910-323-3184
Practice Address - Fax:910-323-9577
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-25
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC13533225100000X
GA010646261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist