Provider Demographics
NPI:1366702177
Name:NAILL, TIMOTHY
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
Last Name:NAILL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PSC 80 BOX 13672
Mailing Address - Street 2:
Mailing Address - City:APO
Mailing Address - State:AP
Mailing Address - Zip Code:96367-0039
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:45TH MDG
Practice Address - Street 2:1381 SOUTH PATRICK DRIVE
Practice Address - City:PATRICK AFB
Practice Address - State:FL
Practice Address - Zip Code:32925
Practice Address - Country:US
Practice Address - Phone:321-494-2184
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-26
Last Update Date:2021-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490147531041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL149.014753OtherUS AIR FORCE
IL149.014735OtherLICENSE