Provider Demographics
NPI:1649538679
Name:CARILLON, KATIE JANETTE (PAC)
Entity type:Individual
Prefix:
First Name:KATIE
Middle Name:JANETTE
Last Name:CARILLON
Suffix:
Gender:F
Credentials:PAC
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Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:11001 EXECUTIVE CENTER DR STE 200
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72211-4393
Mailing Address - Country:US
Mailing Address - Phone:501-851-7402
Mailing Address - Fax:501-851-4753
Practice Address - Street 1:1701 CLUB MANOR DR STE 2B
Practice Address - Street 2:
Practice Address - City:MAUMELLE
Practice Address - State:AR
Practice Address - Zip Code:72113-7401
Practice Address - Country:US
Practice Address - Phone:501-843-4555
Practice Address - Fax:501-743-1550
Is Sole Proprietor?:No
Enumeration Date:2012-04-27
Last Update Date:2024-09-20
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
ARPA468363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical