Provider Demographics
NPI:1265313555
Name:TILLMAN, LATRISHA MARIE
Entity type:Individual
Prefix:
First Name:LATRISHA
Middle Name:MARIE
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 1:21042 WENZE LN
Mailing Address - Street 2:
Mailing Address - City:NEW CANEY
Mailing Address - State:TX
Mailing Address - Zip Code:77357-2561
Mailing Address - Country:US
Mailing Address - Phone:832-543-3426
Mailing Address - Fax:
Practice Address - Street 1:21042 WENZE LN
Practice Address - Street 2:
Practice Address - City:NEW CANEY
Practice Address - State:TX
Practice Address - Zip Code:77357-2561
Practice Address - Country:US
Practice Address - Phone:832-543-3426
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-11
Last Update Date:2025-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332U00000XSuppliersHome Delivered Meals