Provider Demographics
NPI:1922022995
Name:CARRILLO, PRISCILLA T (RN)
Entity Type:Individual
Prefix:MS
First Name:PRISCILLA
Middle Name:T
Last Name:CARRILLO
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:HC 75 BOX 53A
Mailing Address - Street 2:
Mailing Address - City:CHAMA
Mailing Address - State:NM
Mailing Address - Zip Code:87520-9702
Mailing Address - Country:US
Mailing Address - Phone:505-929-4962
Mailing Address - Fax:
Practice Address - Street 1:12000 STONE LAKE RD.
Practice Address - Street 2:
Practice Address - City:DULCE
Practice Address - State:NM
Practice Address - Zip Code:87528
Practice Address - Country:US
Practice Address - Phone:575-759-3291
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2010-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMR53479163WP2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP2201XNursing Service ProvidersRegistered NurseAmbulatory Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM00K3526Medicaid
NMHSZ196OtherMEDICARE PART B
NM00K3526Medicaid