Provider Demographics
NPI:1386938249
Name:TILLER, JACQUELINE ANTOINETTE (MSN,FNP-BC)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:ANTOINETTE
Last Name:TILLER
Suffix:
Gender:F
Credentials:MSN,FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:810 NEW BURTON RD
Mailing Address - Street 2:SUITE #1
Mailing Address - City:DOVER
Mailing Address - State:DE
Mailing Address - Zip Code:19904-5488
Mailing Address - Country:US
Mailing Address - Phone:302-744-9310
Mailing Address - Fax:302-744-9312
Practice Address - Street 1:810 NEW BURTON RD
Practice Address - Street 2:SUITE #1
Practice Address - City:DOVER
Practice Address - State:DE
Practice Address - Zip Code:19904-5488
Practice Address - Country:US
Practice Address - Phone:302-744-9310
Practice Address - Fax:302-744-9312
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-07
Last Update Date:2011-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DELG-0000558363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily