Provider Demographics
NPI:1407327687
Name:CARILLO, KIMBERLY MAE CARREON (NP)
Entity type:Individual
Prefix:
First Name:KIMBERLY MAE
Middle Name:CARREON
Last Name:CARILLO
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:KIMBERLY MAE
Other - Middle Name:RUIZ
Other - Last Name:CARREON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:295 ROUTE 340
Mailing Address - Street 2:
Mailing Address - City:SPARKILL
Mailing Address - State:NY
Mailing Address - Zip Code:10976-1205
Mailing Address - Country:US
Mailing Address - Phone:845-596-1369
Mailing Address - Fax:
Practice Address - Street 1:622 W 168TH ST FL 14
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-3720
Practice Address - Country:US
Practice Address - Phone:212-305-0914
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-16
Last Update Date:2025-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF308369-1363L00000X
NY308369363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner