Provider Demographics
NPI:1265098784
Name:CARRILLO, KEITH (NP)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:
Last Name:CARRILLO
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:920 N LONG BEACH BLVD # 2259
Mailing Address - Street 2:
Mailing Address - City:COMPTON
Mailing Address - State:CA
Mailing Address - Zip Code:90221-2260
Mailing Address - Country:US
Mailing Address - Phone:323-732-0100
Mailing Address - Fax:
Practice Address - Street 1:920 N LONG BEACH BLVD # 2259
Practice Address - Street 2:
Practice Address - City:COMPTON
Practice Address - State:CA
Practice Address - Zip Code:90221-2260
Practice Address - Country:US
Practice Address - Phone:323-732-0100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-10
Last Update Date:2021-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95011765363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily