Provider Demographics
NPI:1114485752
Name:RIESEL, BRENDA
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:
Last Name:RIESEL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 LANSING ST
Mailing Address - Street 2:
Mailing Address - City:HERKIMER
Mailing Address - State:NY
Mailing Address - Zip Code:13350-1228
Mailing Address - Country:US
Mailing Address - Phone:315-868-9760
Mailing Address - Fax:
Practice Address - Street 1:6050 CAVANAUGH RD
Practice Address - Street 2:
Practice Address - City:MARCY
Practice Address - State:NY
Practice Address - Zip Code:13403-2411
Practice Address - Country:US
Practice Address - Phone:315-534-0730
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-02
Last Update Date:2019-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY249344-1251J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251J00000XAgenciesNursing Care