Provider Demographics
NPI:1780239889
Name:TILLEM, KATHERINE (PA-C)
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:
Last Name:TILLEM
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KATHERINE
Other - Middle Name:
Other - Last Name:FIGELLA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8901 STONEBRIDGE BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30134-2254
Mailing Address - Country:US
Mailing Address - Phone:943-202-7120
Mailing Address - Fax:470-986-7087
Practice Address - Street 1:8901 STONEBRIDGE BLVD STE 200
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30134-2254
Practice Address - Country:US
Practice Address - Phone:943-202-7120
Practice Address - Fax:470-986-7087
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-06
Last Update Date:2024-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
GA9345363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty