Provider Demographics
NPI:1063515187
Name:TILLOTSON, KIMBERLY KAY (CNM/NP)
Entity type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:KAY
Last Name:TILLOTSON
Suffix:
Gender:F
Credentials:CNM/NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18300 US HIGHWAY 18
Mailing Address - Street 2:
Mailing Address - City:APPLE VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92307-2206
Mailing Address - Country:US
Mailing Address - Phone:760-242-2311
Mailing Address - Fax:760-946-8875
Practice Address - Street 1:18300 HIGHWAY 18
Practice Address - Street 2:
Practice Address - City:APPLE VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92307-2215
Practice Address - Country:US
Practice Address - Phone:760-242-2311
Practice Address - Fax:760-946-8875
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2008-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANMW1393367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
CANMW0013930Medicaid