Provider Demographics
NPI:1164247524
Name:CARRILLO, ALEXIS S
Entity type:Individual
Prefix:
First Name:ALEXIS
Middle Name:S
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 1:433 CHERRY ST APT 1
Mailing Address - Street 2:
Mailing Address - City:CHICO
Mailing Address - State:CA
Mailing Address - Zip Code:95928-5182
Mailing Address - Country:US
Mailing Address - Phone:707-590-8339
Mailing Address - Fax:
Practice Address - Street 1:433 CHERRY ST APT 1
Practice Address - Street 2:
Practice Address - City:CHICO
Practice Address - State:CA
Practice Address - Zip Code:95928-5182
Practice Address - Country:US
Practice Address - Phone:707-590-8339
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-20
Last Update Date:2024-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86345781133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered