Provider Demographics
NPI:1417456351
Name:CARROLL, PHYLLIS CRISOSTOMO (FNP-C)
Entity Type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:CRISOSTOMO
Last Name:CARROLL
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 HOLLY DR
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94903-2441
Mailing Address - Country:US
Mailing Address - Phone:510-520-0488
Mailing Address - Fax:
Practice Address - Street 1:6100 REDWOOD BLVD
Practice Address - Street 2:
Practice Address - City:NOVATO
Practice Address - State:CA
Practice Address - Zip Code:94945-4501
Practice Address - Country:US
Practice Address - Phone:415-448-1500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-06
Last Update Date:2018-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9008368363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily