Provider Demographics
NPI:1851948046
Name:CARRILLO, DOREEN KELLIE (FNP)
Entity Type:Individual
Prefix:
First Name:DOREEN
Middle Name:KELLIE
Last Name:CARRILLO
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21270 E ASHTON LN
Mailing Address - Street 2:
Mailing Address - City:LINDEN
Mailing Address - State:CA
Mailing Address - Zip Code:95236-9580
Mailing Address - Country:US
Mailing Address - Phone:209-373-5445
Mailing Address - Fax:
Practice Address - Street 1:2800 W MARCH LN
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95219-8218
Practice Address - Country:US
Practice Address - Phone:209-670-8000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-22
Last Update Date:2021-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95012375163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse