MEDICARE: MS. MAYDA ENGRACIA CARRILLO RN DOM NMD

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	163W00000X	Registered Nurse	RN1451192	FL
2	171100000X	Acupuncturist	AP712	FL
3	175F00000X	Naturopath	NAT1000736	DC

General Provider Information

NPI Number	:	1790742302
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MAYDA ENGRACIA CARRILLO RN DOM NMD

Provider Business Mailing Address
First Line	:	1201 SHERIDAN RD
Second Line	:
City	:	CLEARWATER
State	:	FL
Zip	:	33755
Country	:	US
Telephone Number	:	727-449-9090
Fax Number	:	727-449-9090

Provider Business Practice Location Address
First Line	:	1201 SHERIDAN RD
Second Line	:
City	:	CLEARWATER
State	:	FL
Zip	:	33755-1430
Country	:	US
Telephone Number	:	727-449-9090
Fax Number	:	727-449-9090

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

Provider Enumeration Date	:	04/27/2006
Last Update Date	:	08/18/2009

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