Basic Information
| Provider Information | |||||||||
| NPI: | 1124588660 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TILLACK | ||||||||
| FirstName: | CAITLIN | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | ANP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 KINGS HWY S | ||||||||
| Address2: | |||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146175504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5859221900 | ||||||||
| FaxNumber: | 5859220636 | ||||||||
| Practice Location | |||||||||
| Address1: | 495 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | CANANDAIGUA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 144241283 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5853933515 | ||||||||
| FaxNumber: | 5853933526 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/21/2019 | ||||||||
| LastUpdateDate: | 05/25/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LG0600X | 309029 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology |
No ID Information.