Provider Demographics
NPI:1730753435
Name:TILLMAN, GERICA MICHELLE (REGISTERED NURSE)
Entity type:Individual
Prefix:MS
First Name:GERICA
Middle Name:MICHELLE
Last Name:TILLMAN
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 DECATUR ST
Mailing Address - Street 2:
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71111-6258
Mailing Address - Country:US
Mailing Address - Phone:318-347-6653
Mailing Address - Fax:318-675-0543
Practice Address - Street 1:151 FREESTATE BLVD
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71107-6535
Practice Address - Country:US
Practice Address - Phone:318-226-5990
Practice Address - Fax:318-675-0543
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-17
Last Update Date:2022-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA20180753164W00000X
LA206282163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163W00000XNursing Service ProvidersRegistered Nurse
No164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Single Specialty