Provider Demographics
NPI:1427447549
Name:TILLEY, GEANDA
Entity type:Individual
Prefix:
First Name:GEANDA
Middle Name:
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 1:4801 DANUBE LN
Mailing Address - Street 2:APARTMENT #823
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27704-1845
Mailing Address - Country:US
Mailing Address - Phone:919-237-2112
Mailing Address - Fax:
Practice Address - Street 1:4801 DANUBE LN
Practice Address - Street 2:APARTMENT #823
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27704-1845
Practice Address - Country:US
Practice Address - Phone:919-237-2112
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-13
Last Update Date:2015-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC252904314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility