Provider Demographics
NPI:1508471459
Name:TILLMAN, ALLISON ANN
Entity type:Individual
Prefix:
First Name:ALLISON
Middle Name:ANN
Last Name:TILLMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ALLISON
Other - Middle Name:ANN
Other - Last Name:LIBERT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3113 LAWTON RD STE 100
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32803-3519
Mailing Address - Country:US
Mailing Address - Phone:407-894-3241
Mailing Address - Fax:407-896-9863
Practice Address - Street 1:3113 LAWTON RD STE 100
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32803-3519
Practice Address - Country:US
Practice Address - Phone:407-894-3241
Practice Address - Fax:407-896-9863
Is Sole Proprietor?:No
Enumeration Date:2020-09-08
Last Update Date:2024-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11008890363LF0000X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL124782500Medicaid