Basic Information
| Provider Information | |||||||||
| NPI: | 1326330432 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TILLERY | ||||||||
| FirstName: | MONIQUE | ||||||||
| MiddleName: | TAKEISHA | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | TILLERY | ||||||||
| OtherFirstName: | MONIQUE | ||||||||
| OtherMiddleName: | TAKEISHA | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | RN | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4222 RED HAVEN RD | ||||||||
| Address2: | |||||||||
| City: | PIKESVILLE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212085853 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4104847106 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2250 HICKORY RD STE 240 | ||||||||
| Address2: | |||||||||
| City: | PLYMOUTH MEETING | ||||||||
| State: | PA | ||||||||
| PostalCode: | 194622225 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8008794471 | ||||||||
| FaxNumber: | 6108251604 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/08/2011 | ||||||||
| LastUpdateDate: | 05/08/2011 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | R164341 | MD | Y | Nursing Service Providers | Registered Nurse |
ID Information
| ID | Type | State | Issuer | Description | R164341 | 01 | MD | RN LICENSE | OTHER |