Provider Demographics
NPI:1083087852
Name:RILEY, TRACY A (PHD, RN, CNS, CNE)
Entity Type:Individual
Prefix:DR
First Name:TRACY
Middle Name:A
Last Name:RILEY
Suffix:
Gender:F
Credentials:PHD, RN, CNS, CNE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2270 MOHLER DR NW
Mailing Address - Street 2:
Mailing Address - City:NORTH CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44720-5736
Mailing Address - Country:US
Mailing Address - Phone:330-904-3506
Mailing Address - Fax:
Practice Address - Street 1:2270 MOHLER DR NW
Practice Address - Street 2:
Practice Address - City:NORTH CANTON
Practice Address - State:OH
Practice Address - Zip Code:44720-5736
Practice Address - Country:US
Practice Address - Phone:330-904-3506
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-03
Last Update Date:2015-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH02762-NS364SA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHNLN 481258OtherPRIVATE INSURANCE
OHRN-186297OtherPRIVATE INSURANCE
OH02762-NSOtherPRIVATE INSURANCE