Provider Demographics
NPI:1245965144
Name:TILLMAN, SHANNON E (CMA)
Entity type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:E
Last Name:TILLMAN
Suffix:
Gender:F
Credentials:CMA
Other - Prefix:MS
Other - First Name:SHANNON
Other - Middle Name:E
Other - Last Name:GIBSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CMA
Mailing Address - Street 1:6501 ARLINGTON EXPY STE B105
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32211-0810
Mailing Address - Country:US
Mailing Address - Phone:904-351-6479
Mailing Address - Fax:904-212-1996
Practice Address - Street 1:3104 W 12TH ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32254-1808
Practice Address - Country:US
Practice Address - Phone:413-686-2639
Practice Address - Fax:904-212-1996
Is Sole Proprietor?:No
Enumeration Date:2022-07-24
Last Update Date:2022-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL238705376J00000X, 372600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372600000XNursing Service Related ProvidersAdult Companion
No376J00000XNursing Service Related ProvidersHomemaker