Provider Demographics
NPI:1205335569
Name:TILTON, KATRINA ROSE (C-NP)
Entity type:Individual
Prefix:
First Name:KATRINA
Middle Name:ROSE
Last Name:TILTON
Suffix:
Gender:F
Credentials:C-NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3100 MACCORKLE AVE SE STE 205
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25304-1228
Mailing Address - Country:US
Mailing Address - Phone:304-388-2390
Mailing Address - Fax:
Practice Address - Street 1:3100 MACCORKLE AVE SE STE 205
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25304-1228
Practice Address - Country:US
Practice Address - Phone:304-388-2390
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-01
Last Update Date:2025-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV111820363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0242047Medicaid