Provider Demographics
NPI:1043554488
Name:RIDDETT, MARY M (NP-C)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:M
Last Name:RIDDETT
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7938 STRATFORD LN
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30350-4159
Mailing Address - Country:US
Mailing Address - Phone:770-804-9479
Mailing Address - Fax:
Practice Address - Street 1:7938 STRATFORD LN
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30350-4159
Practice Address - Country:US
Practice Address - Phone:770-804-9479
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-26
Last Update Date:2012-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN061255363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner