Provider Demographics
NPI:1609217256
Name:CARLILE, JENNIFER MAE (FNP-C)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MAE
Last Name:CARLILE
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:MAE
Other - Last Name:PARVE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 188
Mailing Address - Street 2:
Mailing Address - City:MARANA
Mailing Address - State:AZ
Mailing Address - Zip Code:85653-0188
Mailing Address - Country:US
Mailing Address - Phone:520-682-4111
Mailing Address - Fax:520-818-3630
Practice Address - Street 1:13395 N MARANA MAIN ST
Practice Address - Street 2:
Practice Address - City:MARANA
Practice Address - State:AZ
Practice Address - Zip Code:85653-7008
Practice Address - Country:US
Practice Address - Phone:520-682-4111
Practice Address - Fax:520-682-3817
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-11
Last Update Date:2021-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP5088363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ829150Medicaid