Healthcare Provider Details

I. General information

NPI: 1922022995
Provider Name (Legal Business Name): PRISCILLA T CARRILLO RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 09/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12000 STONE LAKE RD.
DULCE NM
87528
US

IV. Provider business mailing address

HC 75 BOX 53A
CHAMA NM
87520-9702
US

V. Phone/Fax

Practice location:
  • Phone: 575-759-3291
  • Fax:
Mailing address:
  • Phone: 505-929-4962
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP2201X
TaxonomyAmbulatory Care Registered Nurse
License NumberR53479
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: