Provider Demographics
NPI:1053904680
Name:TILLERY, ANGELICA
Entity type:Individual
Prefix:
First Name:ANGELICA
Middle Name:
Last Name:TILLERY
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 1:42 TITUS RD
Mailing Address - Street 2:
Mailing Address - City:POUGHKEEPSIE
Mailing Address - State:NY
Mailing Address - Zip Code:12603-1431
Mailing Address - Country:US
Mailing Address - Phone:845-325-6717
Mailing Address - Fax:
Practice Address - Street 1:42 TITUS RD
Practice Address - Street 2:
Practice Address - City:POUGHKEEPSIE
Practice Address - State:NY
Practice Address - Zip Code:12603-1431
Practice Address - Country:US
Practice Address - Phone:845-325-6717
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-15
Last Update Date:2021-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY804020163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse