Provider Demographics
NPI:1740755842
Name:TILLMAN, SHAUNDRIA (LPN)
Entity Type:Individual
Prefix:
First Name:SHAUNDRIA
Middle Name:
Last Name:TILLMAN
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5749 TAMPICO RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32244-1736
Mailing Address - Country:US
Mailing Address - Phone:904-537-9701
Mailing Address - Fax:
Practice Address - Street 1:5749 TAMPICO RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32244-1736
Practice Address - Country:US
Practice Address - Phone:904-537-9701
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-04
Last Update Date:2018-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPN5228192164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPN5228192OtherLICENSE PRACTICAL NURSE