Provider Demographics
NPI:1336923812
Name:TILLS, KATHLEEN S
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:S
Last Name:TILLS
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 1:3300 S FISKE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-4306
Mailing Address - Country:US
Mailing Address - Phone:321-434-9564
Mailing Address - Fax:
Practice Address - Street 1:1846 HIGHWAY 1 STE B
Practice Address - Street 2:
Practice Address - City:ROCKLEDGE
Practice Address - State:FL
Practice Address - Zip Code:32955-2822
Practice Address - Country:US
Practice Address - Phone:321-434-9564
Practice Address - Fax:321-434-7078
Is Sole Proprietor?:No
Enumeration Date:2023-08-24
Last Update Date:2024-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11028260363LF0000X
FLAPRN11028260363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL119862500Medicaid
FLRZ885OtherMEDICARE HF