Provider Demographics
NPI:1922172485
Name:CARILLET, TIFFANY NOEL (PA)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:NOEL
Last Name:CARILLET
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2107 DAIRY RD
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32904-5241
Mailing Address - Country:US
Mailing Address - Phone:321-956-8224
Mailing Address - Fax:321-956-8225
Practice Address - Street 1:2107 DAIRY RD
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32904-5241
Practice Address - Country:US
Practice Address - Phone:321-956-8224
Practice Address - Fax:321-956-8225
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2017-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA 9102635363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP00450359OtherRRMCA OR MCA PIN
FL292694600Medicaid
FLU3231XMedicare UPIN
FLQ22544Medicare UPIN
FLP00450359OtherRRMCA OR MCA PIN