Healthcare Provider Details

I. General information

NPI: 1790742302
Provider Name (Legal Business Name): MAYDA ENGRACIA CARRILLO RN DOM NMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2006
Last Update Date: 08/18/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 SHERIDAN RD
CLEARWATER FL
33755-1430
US

IV. Provider business mailing address

1201 SHERIDAN RD
CLEARWATER FL
33755
US

V. Phone/Fax

Practice location:
  • Phone: 727-449-9090
  • Fax: 727-449-9090
Mailing address:
  • Phone: 727-449-9090
  • Fax: 727-449-9090

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN1451192
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAP712
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code175F00000X
TaxonomyNaturopath
License NumberNAT1000736
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: