Basic Information
| Provider Information | |||||||||
| NPI: | 1790264000 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TILLSON | ||||||||
| FirstName: | COLLEEN | ||||||||
| MiddleName: | ELIZABETH | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | MS, FNP-BC, CMSRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5773 LAKE RD | ||||||||
| Address2: | |||||||||
| City: | GALWAY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 120742810 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5184216544 | ||||||||
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| Practice Location | |||||||||
| Address1: | 211 CHURCH ST | ||||||||
| Address2: | |||||||||
| City: | SARATOGA SPRINGS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 128661090 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5185873222 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/08/2018 | ||||||||
| LastUpdateDate: | 08/08/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 343123 | NY | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.