Provider Demographics
NPI:1295729630
Name:CARRILLO, DONNA (APRN)
Entity type:Individual
Prefix:
First Name:DONNA
Middle Name:
Last Name:CARRILLO
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6801 DIXIE HWY
Mailing Address - Street 2:SUITE 130
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40258-3913
Mailing Address - Country:US
Mailing Address - Phone:502-895-1111
Mailing Address - Fax:502-895-1085
Practice Address - Street 1:3940 DUPONT CIR
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4806
Practice Address - Country:US
Practice Address - Phone:502-895-1111
Practice Address - Fax:502-895-1085
Is Sole Proprietor?:No
Enumeration Date:2005-08-31
Last Update Date:2012-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3002353363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY78005790Medicaid
KYP20818Medicare UPIN
KY0097412Medicare ID - Type Unspecified
KY78005790Medicaid
KYK006200Medicare Oscar/Certification