Provider Demographics
NPI:1881000461
Name:KIMBERLY L TILLMAN
Entity Type:Organization
Organization Name:KIMBERLY L TILLMAN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PN.M-IV
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:L
Authorized Official - Last Name:TILLMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:216-246-8014
Mailing Address - Street 1:11410 ASHBURY AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44106-1310
Mailing Address - Country:US
Mailing Address - Phone:216-246-8014
Mailing Address - Fax:
Practice Address - Street 1:11410 ASHBURY AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44106-1310
Practice Address - Country:US
Practice Address - Phone:216-246-8014
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-03
Last Update Date:2014-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN.143666M-IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHPN.143666-M-IVMedicaid