Provider Demographics
NPI:1396060034
Name:CARRILLO, KANDY (PA)
Entity type:Individual
Prefix:MS
First Name:KANDY
Middle Name:
Last Name:CARRILLO
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1145 NE 133RD ST
Mailing Address - Street 2:
Mailing Address - City:NORTH MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33161-4250
Mailing Address - Country:US
Mailing Address - Phone:305-525-0648
Mailing Address - Fax:
Practice Address - Street 1:21301 NW 2ND AVE
Practice Address - Street 2:
Practice Address - City:MIAMI GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33169-2112
Practice Address - Country:US
Practice Address - Phone:305-947-4499
Practice Address - Fax:786-657-2623
Is Sole Proprietor?:No
Enumeration Date:2010-04-06
Last Update Date:2016-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9105235363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant