Provider Demographics
NPI:1104215953
Name:RILEY, GAY (MS, RD, CCN)
Entity Type:Individual
Prefix:MS
First Name:GAY
Middle Name:
Last Name:RILEY
Suffix:
Gender:F
Credentials:MS, RD, CCN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1510 BRAEBURN DR
Mailing Address - Street 2:
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75082-3038
Mailing Address - Country:US
Mailing Address - Phone:800-692-9711
Mailing Address - Fax:
Practice Address - Street 1:1510 BRAEBURN DR
Practice Address - Street 2:
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75082-3038
Practice Address - Country:US
Practice Address - Phone:800-692-9711
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-16
Last Update Date:2015-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT07610133V00000X
NCL001495133V00000X
FLND4912133V00000X
OH4318133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered