Provider Demographics
NPI:1174223788
Name:TILLMAN-KEYES, SARANDA
Entity type:Individual
Prefix:
First Name:SARANDA
Middle Name:
Last Name:TILLMAN-KEYES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 VIRGINIA AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46204-3709
Mailing Address - Country:US
Mailing Address - Phone:317-238-3534
Mailing Address - Fax:
Practice Address - Street 1:220 VIRGINIA AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46204-3709
Practice Address - Country:US
Practice Address - Phone:317-238-3534
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-03
Last Update Date:2023-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71013644A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner