Provider Demographics
NPI:1457897837
Name:TILLER, KELLY (NP-C)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:
Last Name:TILLER
Suffix:
Gender:F
Credentials:NP-C
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 100174
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29202-3174
Mailing Address - Country:US
Mailing Address - Phone:864-512-4500
Mailing Address - Fax:864-512-4505
Practice Address - Street 1:2000 E GREENVILLE ST
Practice Address - Street 2:SUITE 4500
Practice Address - City:ANDERSON
Practice Address - State:SC
Practice Address - Zip Code:29621-1580
Practice Address - Country:US
Practice Address - Phone:864-512-4500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-10
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC20683363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP4370Medicaid
SCSCA0517111OtherMEDICARE