Provider Demographics
NPI:1114539723
Name:RILEY, LISA ANITA
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:ANITA
Last Name:RILEY
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 1:3020 BEDROCK DR
Mailing Address - Street 2:
Mailing Address - City:VILLA RICA
Mailing Address - State:GA
Mailing Address - Zip Code:30180-3422
Mailing Address - Country:US
Mailing Address - Phone:404-550-0582
Mailing Address - Fax:
Practice Address - Street 1:3020 BEDROCK DR
Practice Address - Street 2:
Practice Address - City:VILLA RICA
Practice Address - State:GA
Practice Address - Zip Code:30180-3422
Practice Address - Country:US
Practice Address - Phone:404-550-0582
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-17
Last Update Date:2020-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant