Provider Demographics
NPI:1114470549
Name:RIDDLE, COURTNEY NICOLE (APRN)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:NICOLE
Last Name:RIDDLE
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:COURTNEY
Other - Middle Name:
Other - Last Name:BRYAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 629
Mailing Address - Street 2:
Mailing Address - City:MAGNOLIA
Mailing Address - State:AR
Mailing Address - Zip Code:71754
Mailing Address - Country:US
Mailing Address - Phone:870-235-3555
Mailing Address - Fax:
Practice Address - Street 1:104 HOSPITAL DRIVE
Practice Address - Street 2:
Practice Address - City:MAGNOLIA
Practice Address - State:AR
Practice Address - Zip Code:71753
Practice Address - Country:US
Practice Address - Phone:870-235-3555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-02
Last Update Date:2020-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARR086552163W00000X
LARN131227163W00000X
ARA004849363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR215626758Medicaid