Provider Demographics
NPI:1790742302
Name:CARRILLO, MAYDA ENGRACIA (RN DOM NMD)
Entity Type:Individual
Prefix:MS
First Name:MAYDA
Middle Name:ENGRACIA
Last Name:CARRILLO
Suffix:
Gender:F
Credentials:RN DOM NMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 SHERIDAN RD
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33755
Mailing Address - Country:US
Mailing Address - Phone:727-449-9090
Mailing Address - Fax:727-449-9090
Practice Address - Street 1:1201 SHERIDAN RD
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33755-1430
Practice Address - Country:US
Practice Address - Phone:727-449-9090
Practice Address - Fax:727-449-9090
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2009-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN1451192163W00000X
FLAP712171100000X
DCNAT1000736175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No163W00000XNursing Service ProvidersRegistered Nurse
No175F00000XOther Service ProvidersNaturopath