Provider Demographics
NPI:1093083479
Name:RIGGLE, DOMENIQUE EVETTE (FNP-C)
Entity Type:Individual
Prefix:MRS
First Name:DOMENIQUE
Middle Name:EVETTE
Last Name:RIGGLE
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55741 NATIONAL RD
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:OH
Mailing Address - Zip Code:43912
Mailing Address - Country:US
Mailing Address - Phone:406-354-5727
Mailing Address - Fax:740-635-4575
Practice Address - Street 1:55741 NATIONAL RD
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:OH
Practice Address - Zip Code:43912
Practice Address - Country:US
Practice Address - Phone:406-354-5727
Practice Address - Fax:740-635-4575
Is Sole Proprietor?:No
Enumeration Date:2011-12-13
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV70538363LF0000X
OH12330363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0066619Medicaid