Provider Demographics
NPI:1790821890
Name:CARRILLO, FELICIA ANNA (LMT)
Entity Type:Individual
Prefix:MRS
First Name:FELICIA
Middle Name:ANNA
Last Name:CARRILLO
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 MAY ST
Mailing Address - Street 2:
Mailing Address - City:SHERWOOD
Mailing Address - State:AR
Mailing Address - Zip Code:72120-3814
Mailing Address - Country:US
Mailing Address - Phone:501-833-3553
Mailing Address - Fax:
Practice Address - Street 1:636 W BROADWAY ST
Practice Address - Street 2:
Practice Address - City:NORTH LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72114-5526
Practice Address - Country:US
Practice Address - Phone:501-374-1153
Practice Address - Fax:501-374-6213
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR4643171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor