Healthcare Provider Details

I. General information

NPI: 1689121931
Provider Name (Legal Business Name): MARTHA CARRILLO PH.D., F NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/03/2016
Last Update Date: 03/24/2025
Certification Date: 03/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 E MITCHELL DR STE 100&200
PHOENIX AZ
85012-2330
US

IV. Provider business mailing address

3003 N CENTRAL AVE STE 400
PHOENIX AZ
85012-2929
US

V. Phone/Fax

Practice location:
  • Phone: 602-685-6000
  • Fax: 602-264-4095
Mailing address:
  • Phone: 602-685-6000
  • Fax: 602-302-7925

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberTAP8960
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAP8960
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: