Provider Demographics
NPI:1073768990
Name:ANDERSON-RIDDELL, JESSICA LYNN (ARNP)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:LYNN
Last Name:ANDERSON-RIDDELL
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:LYNN
Other - Last Name:ANDERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ARNP
Mailing Address - Street 1:2234 COLONIAL BLVD
Mailing Address - Street 2:ATTN: PAYER CONTRACTING & RELATIONS DEPT.
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-1412
Mailing Address - Country:US
Mailing Address - Phone:239-931-7342
Mailing Address - Fax:239-931-7385
Practice Address - Street 1:28930 TRAILS EDGE BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:BONITA SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34134-7518
Practice Address - Country:US
Practice Address - Phone:239-293-0294
Practice Address - Fax:239-992-5785
Is Sole Proprietor?:No
Enumeration Date:2008-11-19
Last Update Date:2013-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9283140363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP01232801OtherRAILROAD MCR
FL009559000Medicaid
FL009559000Medicaid
FLBL002ZMedicare PIN