Provider Demographics
NPI:1306972096
Name:TILLEY, MELANIE ANN
Entity type:Individual
Prefix:
First Name:MELANIE
Middle Name:ANN
Last Name:TILLEY
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 1:6878 DAVE DR
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:OH
Mailing Address - Zip Code:44057
Mailing Address - Country:US
Mailing Address - Phone:440-840-4613
Mailing Address - Fax:440-428-3852
Practice Address - Street 1:6878 DAVE DR
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:OH
Practice Address - Zip Code:44057
Practice Address - Country:US
Practice Address - Phone:440-840-4613
Practice Address - Fax:440-428-3852
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-26
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN.279975163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2204288Medicaid