Provider Demographics
NPI:1932734746
Name:TILLER, KYMBERLI ANGELINA (MSN, APRN, FNP-C)
Entity type:Individual
Prefix:MRS
First Name:KYMBERLI
Middle Name:ANGELINA
Last Name:TILLER
Suffix:
Gender:F
Credentials:MSN, APRN, FNP-C
Other - Prefix:
Other - First Name:KYMBERLI
Other - Middle Name:
Other - Last Name:CONN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:1949 W RAY RD STE 23
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85224-4008
Mailing Address - Country:US
Mailing Address - Phone:480-917-1720
Mailing Address - Fax:480-917-6934
Practice Address - Street 1:1949 W RAY RD STE 23
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85224-4008
Practice Address - Country:US
Practice Address - Phone:480-917-1720
Practice Address - Fax:480-917-6934
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-12
Last Update Date:2024-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP145423363LA2200X
AZ308860363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1518039965Medicaid