Basic Information
| Provider Information | |||||||||
| NPI: | 1104944420 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TILLAR | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | HAGEN | ||||||||
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| Credential: | R.N. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7819 BLERIOT AVE | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900452904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3106493239 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2021 SANTA MONICA BLVD | ||||||||
| Address2: | SUIT 400E | ||||||||
| City: | SANTA MONICA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 904042208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3104535654 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/26/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WX0200X | 375548 | CA | Y | Nursing Service Providers | Registered Nurse | Oncology |
No ID Information.