Provider Demographics
NPI:1760166110
Name:TILLLIS, KENDALL
Entity Type:Individual
Prefix:
First Name:KENDALL
Middle Name:
Last Name:TILLLIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8808 GREENLEAVES DR
Mailing Address - Street 2:
Mailing Address - City:DENHAM SPRINGS
Mailing Address - State:LA
Mailing Address - Zip Code:70726-6742
Mailing Address - Country:US
Mailing Address - Phone:985-981-1435
Mailing Address - Fax:
Practice Address - Street 1:8808 GREENLEAVES DR
Practice Address - Street 2:
Practice Address - City:DENHAM SPRINGS
Practice Address - State:LA
Practice Address - Zip Code:70726-6742
Practice Address - Country:US
Practice Address - Phone:985-981-1435
Practice Address - Fax:225-612-6347
Is Sole Proprietor?:No
Enumeration Date:2023-06-14
Last Update Date:2023-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator