=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780279786
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CARINNA WILMOT PMHNP-BC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/02/2021
-----------------------------------------------------
Last Update Date | 03/08/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2733 PLAYER AVE
-----------------------------------------------------
City | SIERRA VISTA
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85650-5207
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-249-6286
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2733 PLAYER AVE
-----------------------------------------------------
City | SIERRA VISTA
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85650-5207
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-249-6877
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | 272068
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------