MEDICARE: MRS. LORENA CARRILLO HENDERSON RN, FNP-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP2300X	Primary Care Nurse Practitioner	CNP-02601	NM
2	363LF0000X	Family Nurse Practitioner	607418	TX

General Provider Information

NPI Number	:	1013286830
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LORENA CARRILLO HENDERSON RN, FNP-C

Provider Business Mailing Address
First Line	:	7248 CANYON WREN AVE
Second Line	:
City	:	EL PASO
State	:	TX
Zip	:	79911-3067
Country	:	US
Telephone Number	:	915-613-7716
Fax Number	:	855-710-7290

Provider Business Practice Location Address
First Line	:	4301 N MESA ST STE 100
Second Line	:
City	:	EL PASO
State	:	TX
Zip	:	79902-1118
Country	:	US
Telephone Number	:	915-613-7716
Fax Number	:	855-710-7290

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/22/2011
Last Update Date	:	01/10/2022

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