Provider Demographics
NPI:1023848504
Name:CARRILLO, LISA MARIE (CERTIFIED PFA)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:CARRILLO
Suffix:
Gender:
Credentials:CERTIFIED PFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18818 US HIGHWAY 18
Mailing Address - Street 2:
Mailing Address - City:APPLE VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92307-2323
Mailing Address - Country:US
Mailing Address - Phone:760-995-8891
Mailing Address - Fax:
Practice Address - Street 1:18818 US HIGHWAY 18
Practice Address - Street 2:
Practice Address - City:APPLE VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92307-2323
Practice Address - Country:US
Practice Address - Phone:760-995-8891
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-07
Last Update Date:2025-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
175T00000X
CAMPSSVGHYZX372600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372600000XNursing Service Related ProvidersAdult Companion
No175T00000XOther Service ProvidersPeer Specialist