Provider Demographics
NPI:1760926505
Name:EASLEY, TILLANA ANGEL
Entity Type:Individual
Prefix:
First Name:TILLANA
Middle Name:ANGEL
Last Name:EASLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2850 E BONANZA RD
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89101-3600
Mailing Address - Country:US
Mailing Address - Phone:702-234-7049
Mailing Address - Fax:
Practice Address - Street 1:2850 E BONANZA RD APT 2115
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89101-8212
Practice Address - Country:US
Practice Address - Phone:702-234-7049
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-13
Last Update Date:2016-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician