Provider Demographics
NPI:1962723452
Name:TILQUIST, KELLI D (LMT)
Entity type:Individual
Prefix:
First Name:KELLI
Middle Name:D
Last Name:TILQUIST
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5169 S UNIVERSITY DR
Mailing Address - Street 2:
Mailing Address - City:DAVIE
Mailing Address - State:FL
Mailing Address - Zip Code:33328-4508
Mailing Address - Country:US
Mailing Address - Phone:954-805-5488
Mailing Address - Fax:
Practice Address - Street 1:5169 S UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:DAVIE
Practice Address - State:FL
Practice Address - Zip Code:33328-4508
Practice Address - Country:US
Practice Address - Phone:954-805-5488
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-18
Last Update Date:2010-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA16221173C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes173C00000XOther Service ProvidersReflexologist