Provider Demographics
NPI:1154671667
Name:CARRILLO, TRACY
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:CARRILLO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3055 S SIERRA HEIGHTS CIR
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85212-2863
Mailing Address - Country:US
Mailing Address - Phone:480-247-7781
Mailing Address - Fax:
Practice Address - Street 1:10045 E MADERO AVE
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85209-1399
Practice Address - Country:US
Practice Address - Phone:480-984-8947
Practice Address - Fax:480-354-5090
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-12
Last Update Date:2012-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator