Provider Demographics
NPI:1063806214
Name:CARRILLO, KELLY (CRNA)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:CARRILLO
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:VROEGH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:4237 E KILMER ST
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85711-2825
Mailing Address - Country:US
Mailing Address - Phone:520-539-8905
Mailing Address - Fax:
Practice Address - Street 1:1625 N CAMPBELL AVE
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85719-4330
Practice Address - Country:US
Practice Address - Phone:520-792-1450
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-26
Last Update Date:2024-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ261429207L00000X
AZRN176261163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology