Provider Demographics
NPI:1124746573
Name:TILLMAN, ASHLEY KEYONA
Entity type:Individual
Prefix:
First Name:ASHLEY
Middle Name:KEYONA
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 1:4001 S CAPITOL ST SW APT 525
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20032-1388
Mailing Address - Country:US
Mailing Address - Phone:202-361-6914
Mailing Address - Fax:
Practice Address - Street 1:4001 S CAPITOL ST SW APT 525
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20032-1388
Practice Address - Country:US
Practice Address - Phone:202-361-6914
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-19
Last Update Date:2022-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3747P1801X
DC3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC3747P1801XMedicaid