Basic Information
| Provider Information | |||||||||
| NPI: | 1780239889 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TILLEM | ||||||||
| FirstName: | KATHERINE | ||||||||
| MiddleName: | |||||||||
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| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | FIGELLA | ||||||||
| OtherFirstName: | KATHERINE | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1201 GEORGIAN PARK | ||||||||
| Address2: | |||||||||
| City: | PEACHTREE CITY | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30269 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 209 COOLEY DR STE 101 | ||||||||
| Address2: | |||||||||
| City: | VILLA RICA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301807057 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7704560911 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/06/2019 | ||||||||
| LastUpdateDate: | 03/30/2022 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/30/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 9345 | GA | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.