Provider Demographics
NPI:1376848457
Name:DAVILA, CARRIE ANN (PA)
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:ANN
Last Name:DAVILA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:CARRIE
Other - Middle Name:ANN
Other - Last Name:LOSITO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1397 MEDICAL PARK BLVD STE 220
Mailing Address - Street 2:
Mailing Address - City:WELLINGTON
Mailing Address - State:FL
Mailing Address - Zip Code:33414-3187
Mailing Address - Country:US
Mailing Address - Phone:561-784-0202
Mailing Address - Fax:561-641-7732
Practice Address - Street 1:1397 MEDICAL PARK BLVD STE 220
Practice Address - Street 2:
Practice Address - City:WELLINGTON
Practice Address - State:FL
Practice Address - Zip Code:33414-3187
Practice Address - Country:US
Practice Address - Phone:561-784-0202
Practice Address - Fax:561-641-7732
Is Sole Proprietor?:No
Enumeration Date:2011-01-20
Last Update Date:2011-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9105629363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant