Provider Demographics
NPI:1427449529
Name:TILLER, SONJA FAYE (FNP-C)
Entity type:Individual
Prefix:
First Name:SONJA
Middle Name:FAYE
Last Name:TILLER
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:SONJA
Other - Middle Name:JONES
Other - Last Name:TILLER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RN
Mailing Address - Street 1:21835 COUNTY ROAD 2160
Mailing Address - Street 2:
Mailing Address - City:TROUP
Mailing Address - State:TX
Mailing Address - Zip Code:75789-6003
Mailing Address - Country:US
Mailing Address - Phone:903-570-8612
Mailing Address - Fax:
Practice Address - Street 1:8288 S BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-5262
Practice Address - Country:US
Practice Address - Phone:903-606-7060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-10
Last Update Date:2022-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP127124363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8708NNOtherBCBS
TX752616977-18OtherTRICARE
TX346907401Medicaid
TXP01464097OtherMEDICARE RAILROAD
TX402865YMAFMedicare PIN