Provider Demographics
NPI:1205983095
Name:TILLER, PATRICIA L (CARE PROVIDER)
Entity type:Individual
Prefix:
First Name:PATRICIA
Middle Name:L
Last Name:TILLER
Suffix:
Gender:F
Credentials:CARE PROVIDER
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 582
Mailing Address - Street 2:312 E. EARP ST.
Mailing Address - City:HOLLY SPRINGS
Mailing Address - State:NC
Mailing Address - Zip Code:27540-0582
Mailing Address - Country:US
Mailing Address - Phone:919-552-4849
Mailing Address - Fax:919-557-7391
Practice Address - Street 1:312 E. EARP ST
Practice Address - Street 2:
Practice Address - City:HOLLY SPRINGS
Practice Address - State:NC
Practice Address - Zip Code:27540-0582
Practice Address - Country:US
Practice Address - Phone:919-552-4849
Practice Address - Fax:919-557-7391
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCFCL-092-042177F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes177F00000XOther Service ProvidersLodging
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7801833Medicaid