Basic Information
| Provider Information | |||||||||
| NPI: | 1215243647 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TILLIS | ||||||||
| FirstName: | CARILISS | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LVN | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 600 B ST STE 1570 | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921014560 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6196150439 | ||||||||
| FaxNumber: | 6196153197 | ||||||||
| Practice Location | |||||||||
| Address1: | 600 B ST STE 1570 | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921014560 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6196150439 | ||||||||
| FaxNumber: | 6196153197 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2010 | ||||||||
| LastUpdateDate: | 08/23/2010 | ||||||||
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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 | 164X00000X | 187272 | CA | Y | Nursing Service Providers | Licensed Vocational Nurse |
No ID Information.