Provider Demographics
NPI:1679027114
Name:CARRILLO, BEATRICE (APN)
Entity Type:Individual
Prefix:
First Name:BEATRICE
Middle Name:
Last Name:CARRILLO
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:145 S DEAN ST
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07631-3513
Mailing Address - Country:US
Mailing Address - Phone:201-308-5591
Mailing Address - Fax:
Practice Address - Street 1:145 S DEAN ST
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07631-3513
Practice Address - Country:US
Practice Address - Phone:201-308-5591
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-13
Last Update Date:2016-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00655300363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1005116Medicaid
NJ1005116010Medicare NSC
NJ1005116Medicare UPIN
NJ1005116Medicare Oscar/Certification
NJ1005116Medicare PIN