Provider Demographics
NPI:1770082174
Name:TILLMAN, RACHELL LYNN (FL MA 76980)
Entity type:Individual
Prefix:
First Name:RACHELL
Middle Name:LYNN
Last Name:TILLMAN
Suffix:
Gender:F
Credentials:FL MA 76980
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 VERACRUZ DR UNIT 813
Mailing Address - Street 2:
Mailing Address - City:PONTE VEDRA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32082-3251
Mailing Address - Country:US
Mailing Address - Phone:423-444-9893
Mailing Address - Fax:
Practice Address - Street 1:2380 3RD ST S STE 2
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32250-8038
Practice Address - Country:US
Practice Address - Phone:423-444-9893
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-12
Last Update Date:2018-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL76980225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist