Provider Demographics
NPI:1902394745
Name:TILLMAN EDISON, LISA
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:
Last Name:TILLMAN EDISON
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:PO BOX 3017
Mailing Address - Street 2:
Mailing Address - City:HARVEY
Mailing Address - State:LA
Mailing Address - Zip Code:70059-3017
Mailing Address - Country:US
Mailing Address - Phone:504-451-7337
Mailing Address - Fax:
Practice Address - Street 1:2331 CANAL ST
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70119-6503
Practice Address - Country:US
Practice Address - Phone:304-307-3737
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-26
Last Update Date:2018-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation