Provider Demographics
NPI:1861459042
Name:TILLACK, PATRICIA SUE (ANP)
Entity Type:Individual
Prefix:MS
First Name:PATRICIA
Middle Name:SUE
Last Name:TILLACK
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:MRS
Other - First Name:PATRICIA
Other - Middle Name:SUE
Other - Last Name:ORMSBY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ANP
Mailing Address - Street 1:9224 N 28TH ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85028-4705
Mailing Address - Country:US
Mailing Address - Phone:602-510-6977
Mailing Address - Fax:602-795-1442
Practice Address - Street 1:9224 N 28TH ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85028-4705
Practice Address - Country:US
Practice Address - Phone:602-510-6977
Practice Address - Fax:602-795-1442
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ186363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health