Provider Demographics
NPI:1154828291
Name:RILEY, ENDYE
Entity Type:Individual
Prefix:
First Name:ENDYE
Middle Name:
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 1:208 N MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:LANSDOWNE
Mailing Address - State:PA
Mailing Address - Zip Code:19050-1609
Mailing Address - Country:US
Mailing Address - Phone:610-931-0361
Mailing Address - Fax:
Practice Address - Street 1:208 N MAPLE AVE
Practice Address - Street 2:
Practice Address - City:LANSDOWNE
Practice Address - State:PA
Practice Address - Zip Code:19050-1609
Practice Address - Country:US
Practice Address - Phone:610-931-0361
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-06
Last Update Date:2018-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA82-4567121Medicaid