Active NPI
Jane B Tilly, RN
- Registered Nurse
- West Bend, WI
National Provider Identifier
1609827690
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Registered Nurse
- License
- 78518-030
- Practice address
- 770 Pennsylvania Ave
West Bend, WI 53095-4142 - Phone
- (262) 339-4752
- NPI assigned
- May 13, 2006
- Sex
- Female
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Registered Nurse | 163W00000X | 78518-030 | WI | Primary |
Addresses
Primary practice location
770 Pennsylvania Ave
West Bend, WI 53095-4142
Mailing address
770 Pennsylvania Ave
West Bend, WI 53095-4142
Phone (262) 339-4752
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 39930300 | Medicaid | WI |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
- Credentials
- Registered Nurse
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 78518-030 | WI | MD | Registered Nurse |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1147478400000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1235347200000",
"number": "1609827690",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "770 PENNSYLVANIA AVE",
"city": "WEST BEND",
"state": "WI",
"postal_code": "530954142",
"telephone_number": "262-339-4752"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "770 PENNSYLVANIA AVE",
"city": "WEST BEND",
"state": "WI",
"postal_code": "530954142",
"telephone_number": "262-339-4752"
}
],
"practiceLocations": [],
"basic": {
"last_name": "TILLY",
"first_name": "JANE",
"middle_name": "B",
"credential": "RN",
"sole_proprietor": "YES",
"sex": "F",
"enumeration_date": "2006-05-13",
"last_updated": "2009-02-23",
"status": "A"
},
"taxonomies": [
{
"code": "163W00000X",
"taxonomy_group": "",
"desc": "Registered Nurse",
"state": "WI",
"license": "78518-030",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "39930300",
"state": "WI"
}
],
"endpoints": [],
"other_names": []
}Other providers in West Bend, WI
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 23, 2009; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.