Provider Demographics
NPI:1720648140
Name:TILLMAN, KATHERINE KELLE (APRN ACNS-BC)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:KELLE
Last Name:TILLMAN
Suffix:
Gender:F
Credentials:APRN ACNS-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1308 CLAIBORNE LN
Mailing Address - Street 2:
Mailing Address - City:ALEDO
Mailing Address - State:TX
Mailing Address - Zip Code:76008-5803
Mailing Address - Country:US
Mailing Address - Phone:817-223-5231
Mailing Address - Fax:817-257-7279
Practice Address - Street 1:1717 S MAIN ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76110-1626
Practice Address - Country:US
Practice Address - Phone:817-332-7722
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-18
Last Update Date:2019-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP129952163WA2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA2000XNursing Service ProvidersRegistered NurseAdministrator