Provider Demographics
NPI:1174190268
Name:RILEY, SIERRA MARIE
Entity Type:Individual
Prefix:
First Name:SIERRA
Middle Name:MARIE
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 1:3797 HIGHWAY 30 W
Mailing Address - Street 2:
Mailing Address - City:NEW PLYMOUTH
Mailing Address - State:ID
Mailing Address - Zip Code:83655-5144
Mailing Address - Country:US
Mailing Address - Phone:208-781-1150
Mailing Address - Fax:
Practice Address - Street 1:910 NW 16TH ST # 200
Practice Address - Street 2:
Practice Address - City:FRUITLAND
Practice Address - State:ID
Practice Address - Zip Code:83619-2265
Practice Address - Country:US
Practice Address - Phone:208-452-8060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-07
Last Update Date:2021-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-7256225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist