Provider Demographics
NPI:1194932624
Name:TILLEY DERRICK, KATHRYN (RD, LD)
Entity type:Individual
Prefix:MRS
First Name:KATHRYN
Middle Name:
Last Name:TILLEY DERRICK
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:127 WC BRYANT PKWY
Mailing Address - Street 2:STE A
Mailing Address - City:CALHOUN
Mailing Address - State:GA
Mailing Address - Zip Code:30701-2654
Mailing Address - Country:US
Mailing Address - Phone:706-629-4999
Mailing Address - Fax:706-629-4799
Practice Address - Street 1:127 WC BRYANT PKWY
Practice Address - Street 2:STE A
Practice Address - City:CALHOUN
Practice Address - State:GA
Practice Address - Zip Code:30701-2654
Practice Address - Country:US
Practice Address - Phone:706-629-4999
Practice Address - Fax:706-629-4799
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-16
Last Update Date:2011-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD003040133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered