Provider Demographics
NPI:1215337142
Name:TILLMAN, SHARON (LPN)
Entity type:Individual
Prefix:MS
First Name:SHARON
Middle Name:
Last Name:TILLMAN
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3368 E 66TH ST
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44127-1905
Mailing Address - Country:US
Mailing Address - Phone:216-341-0208
Mailing Address - Fax:
Practice Address - Street 1:3368 E 66TH ST
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44127-1905
Practice Address - Country:US
Practice Address - Phone:216-341-0208
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-28
Last Update Date:2014-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN.084599-MEDS164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0125671Medicaid