Provider Demographics
NPI:1154946721
Name:TILLISON, TINA MICHELE (APRN, CNP)
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:MICHELE
Last Name:TILLISON
Suffix:
Gender:F
Credentials:APRN, CNP
Other - Prefix:
Other - First Name:TINA
Other - Middle Name:MICHELE
Other - Last Name:PRICE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:APRN-CNP
Mailing Address - Street 1:7800 NW 85TH TER
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73132-3385
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5224 E I 240 SERVICE RD STE 201
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73135-2607
Practice Address - Country:US
Practice Address - Phone:405-608-3800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-10
Last Update Date:2023-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK89076363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner