Provider Demographics
NPI:1851852875
Name:CARBALLOSA, LILIAN R
Entity Type:Individual
Prefix:
First Name:LILIAN
Middle Name:R
Last Name:CARBALLOSA
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 1:14343 SW 163RD TER
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33177-1811
Mailing Address - Country:US
Mailing Address - Phone:786-738-4297
Mailing Address - Fax:
Practice Address - Street 1:14343 SW 163RD TER
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33177-1811
Practice Address - Country:US
Practice Address - Phone:786-738-4297
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-31
Last Update Date:2019-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11001892363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily