Provider Demographics
NPI:1689030330
Name:TILLMAN, KATHERINE
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:
Last Name:TILLMAN
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 1:8119 N MULBERRY ST
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33604-3443
Mailing Address - Country:US
Mailing Address - Phone:813-410-6159
Mailing Address - Fax:
Practice Address - Street 1:8119 N MULBERRY ST
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33604-3443
Practice Address - Country:US
Practice Address - Phone:813-410-6159
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-11
Last Update Date:2025-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCL1189677335E00000X
FL6906834311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
No335E00000XSuppliersProsthetic/Orthotic Supplier