Provider Demographics
NPI:1326851478
Name:CARRILLO, MAYRA
Entity type:Individual
Prefix:
First Name:MAYRA
Middle Name:
Last Name:CARRILLO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2019 SAN SIMEON ST
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89108-3352
Mailing Address - Country:US
Mailing Address - Phone:702-810-2310
Mailing Address - Fax:
Practice Address - Street 1:2019 SAN SIMEON ST
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89108-3352
Practice Address - Country:US
Practice Address - Phone:702-810-2310
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-30
Last Update Date:2025-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA605-674-343171R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171R00000XOther Service ProvidersInterpreter