Provider Demographics
NPI:1255482568
Name:RILEY, SANDRA KEPP (LPN)
Entity Type:Individual
Prefix:MS
First Name:SANDRA
Middle Name:KEPP
Last Name:RILEY
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6140 ORCHARD HILL BLVD
Mailing Address - Street 2:
Mailing Address - City:LORAIN
Mailing Address - State:OH
Mailing Address - Zip Code:44053-3858
Mailing Address - Country:US
Mailing Address - Phone:440-233-7659
Mailing Address - Fax:
Practice Address - Street 1:6140 ORCHARD HILL BLVD
Practice Address - Street 2:
Practice Address - City:LORAIN
Practice Address - State:OH
Practice Address - Zip Code:44053-3858
Practice Address - Country:US
Practice Address - Phone:440-233-7659
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN058547IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2309228Medicaid