Provider Demographics
NPI:1619794856
Name:TILLERY, TAWANDA TENIKA
Entity type:Individual
Prefix:
First Name:TAWANDA
Middle Name:TENIKA
Last Name:TILLERY
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 1:910 JENKINS FARM RD
Mailing Address - Street 2:
Mailing Address - City:PINETOPS
Mailing Address - State:NC
Mailing Address - Zip Code:27864-7022
Mailing Address - Country:US
Mailing Address - Phone:252-640-9194
Mailing Address - Fax:
Practice Address - Street 1:910 JENKINS FARM RD
Practice Address - Street 2:
Practice Address - City:PINETOPS
Practice Address - State:NC
Practice Address - Zip Code:27864-7022
Practice Address - Country:US
Practice Address - Phone:252-640-9194
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-19
Last Update Date:2025-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker