Provider Demographics
NPI:1568959963
Name:CARRILLO, ANISSA (ATC)
Entity Type:Individual
Prefix:
First Name:ANISSA
Middle Name:
Last Name:CARRILLO
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1025 PETERLYNN DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92154-2558
Mailing Address - Country:US
Mailing Address - Phone:619-701-7035
Mailing Address - Fax:
Practice Address - Street 1:347 S GLADSTONE AVE
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60506-4877
Practice Address - Country:US
Practice Address - Phone:619-701-7035
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-20
Last Update Date:2019-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer