Provider Demographics
NPI:1285746941
Name:TILLMAN, COURTENAY L (FNP-BC)
Entity type:Individual
Prefix:
First Name:COURTENAY
Middle Name:L
Last Name:TILLMAN
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:586 BRANNEN ST
Mailing Address - Street 2:
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30458-5557
Mailing Address - Country:US
Mailing Address - Phone:912-871-6611
Mailing Address - Fax:912-871-6612
Practice Address - Street 1:586 BRANNEN ST
Practice Address - Street 2:
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-5557
Practice Address - Country:US
Practice Address - Phone:912-871-6611
Practice Address - Fax:912-871-6612
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2015-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN 159370NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA901106018AMedicaid
GAP00351681OtherRAILROAD MEDICARE
GA061407OtherBC/BS OF GA GROUP #
GA901106018AMedicaid
GA50BBKGVMedicare PIN