Provider Demographics
NPI:1104362359
Name:CARSILLO, NICOLETTE JULIANNE (LAT, ATC)
Entity Type:Individual
Prefix:MISS
First Name:NICOLETTE
Middle Name:JULIANNE
Last Name:CARSILLO
Suffix:
Gender:F
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3527 N VALDOSTA RD
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-6418
Mailing Address - Country:US
Mailing Address - Phone:229-247-2290
Mailing Address - Fax:229-247-9627
Practice Address - Street 1:3527 N VALDOSTA RD
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-6418
Practice Address - Country:US
Practice Address - Phone:229-247-2290
Practice Address - Fax:229-247-9627
Is Sole Proprietor?:No
Enumeration Date:2017-01-12
Last Update Date:2017-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAT0028632255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer