Provider Demographics
NPI:1104944420
Name:TILLAR, KIMBERLY HAGEN (RN)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:HAGEN
Last Name:TILLAR
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7819 BLERIOT AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-2904
Mailing Address - Country:US
Mailing Address - Phone:310-649-3239
Mailing Address - Fax:
Practice Address - Street 1:2021 SANTA MONICA BLVD
Practice Address - Street 2:SUIT 400E
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-2208
Practice Address - Country:US
Practice Address - Phone:310-453-5654
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA375548163WX0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WX0200XNursing Service ProvidersRegistered NurseOncology