Provider Demographics
NPI:1750120796
Name:TILLMAN, SHONTELL M
Entity type:Individual
Prefix:
First Name:SHONTELL
Middle Name:M
Last Name:TILLMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2301 CALIFORNIA AVE
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48601-5307
Mailing Address - Country:US
Mailing Address - Phone:989-964-9415
Mailing Address - Fax:
Practice Address - Street 1:2301 CALIFORNIA AVE
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48601-5307
Practice Address - Country:US
Practice Address - Phone:989-964-9415
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-20
Last Update Date:2024-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372500000XNursing Service Related ProvidersChore Provider