Provider Demographics
NPI:1336171784
Name:TILLEY-CHRISTOPHERSON, VANESSA (OD)
Entity Type:Individual
Prefix:DR
First Name:VANESSA
Middle Name:
Last Name:TILLEY-CHRISTOPHERSON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:VANESSA
Other - Middle Name:
Other - Last Name:TATNEY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:6419 SKILLMAN ST
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75231-7109
Mailing Address - Country:US
Mailing Address - Phone:214-503-0997
Mailing Address - Fax:214-503-0657
Practice Address - Street 1:6419 SKILLMAN ST
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75231-7109
Practice Address - Country:US
Practice Address - Phone:214-503-0997
Practice Address - Fax:214-503-0657
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2009-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.1131-225T152W00000X
TX6883TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1994103Medicaid
U51265Medicare UPIN
LA1994103Medicaid