Provider Demographics
NPI:1184916207
Name:TILLMAN, HARRIET DELORES
Entity type:Individual
Prefix:MS
First Name:HARRIET
Middle Name:DELORES
Last Name:TILLMAN
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 1:36750 US HIGHWAY 19 N
Mailing Address - Street 2:SUITE 3151
Mailing Address - City:PALM HARBOR
Mailing Address - State:FL
Mailing Address - Zip Code:34684-1239
Mailing Address - Country:US
Mailing Address - Phone:813-389-0137
Mailing Address - Fax:727-940-3784
Practice Address - Street 1:36750 US HIGHWAY 19 N
Practice Address - Street 2:SUITE 3151
Practice Address - City:PALM HARBOR
Practice Address - State:FL
Practice Address - Zip Code:34684-1239
Practice Address - Country:US
Practice Address - Phone:813-389-0137
Practice Address - Fax:727-940-3784
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-08
Last Update Date:2011-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003031700Medicare PIN