Provider Demographics
NPI:1790401917
Name:CARRILLO, STACY AILEEN
Entity Type:Individual
Prefix:MS
First Name:STACY
Middle Name:AILEEN
Last Name:CARRILLO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 WALKER ST
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06040-4339
Mailing Address - Country:US
Mailing Address - Phone:860-680-5096
Mailing Address - Fax:
Practice Address - Street 1:45 WADSWORTH ST
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06106-7108
Practice Address - Country:US
Practice Address - Phone:860-680-5096
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-19
Last Update Date:2022-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program