Provider Demographics
NPI:1457533291
Name:CARRILLO-FULK, LINA MICHELLE (RN, PHN)
Entity Type:Individual
Prefix:
First Name:LINA
Middle Name:MICHELLE
Last Name:CARRILLO-FULK
Suffix:
Gender:F
Credentials:RN, PHN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4065 COUNTY CIRCLE DR
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92503-3410
Mailing Address - Country:US
Mailing Address - Phone:951-210-1349
Mailing Address - Fax:
Practice Address - Street 1:308 EAST SAN JACINTO AVENUE
Practice Address - Street 2:
Practice Address - City:PERRIS
Practice Address - State:CA
Practice Address - Zip Code:92570
Practice Address - Country:US
Practice Address - Phone:951-210-1349
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-04
Last Update Date:2007-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA257962163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health