Provider Demographics
NPI:1154672566
Name:CARRILLO, SHIRLEY (FNP)
Entity Type:Individual
Prefix:
First Name:SHIRLEY
Middle Name:
Last Name:CARRILLO
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2109 TRUMAN LN
Mailing Address - Street 2:
Mailing Address - City:OAKLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94561-3991
Mailing Address - Country:US
Mailing Address - Phone:925-522-9689
Mailing Address - Fax:
Practice Address - Street 1:2109 TRUMAN LN
Practice Address - Street 2:
Practice Address - City:OAKLEY
Practice Address - State:CA
Practice Address - Zip Code:94561-3991
Practice Address - Country:US
Practice Address - Phone:925-522-9689
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-25
Last Update Date:2012-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA503951363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner