Provider Demographics
NPI:1366509895
Name:TILSON, KATHERINE MARIE (ARNP)
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:MARIE
Last Name:TILSON
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4315 HIGHLAND PARK BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33813-1639
Mailing Address - Country:US
Mailing Address - Phone:863-816-5884
Mailing Address - Fax:863-940-4856
Practice Address - Street 1:4315 HIGHLAND PARK BLVD STE A
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33813-1639
Practice Address - Country:US
Practice Address - Phone:863-816-5884
Practice Address - Fax:863-940-4856
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2017-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1102742363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL305087400Medicaid
FLE7927Medicare ID - Type Unspecified