Provider Demographics
NPI:1346481389
Name:RILEY, MARYELLEN AGNES (WHNP, RN,C, MS)
Entity Type:Individual
Prefix:
First Name:MARYELLEN
Middle Name:AGNES
Last Name:RILEY
Suffix:
Gender:F
Credentials:WHNP, RN,C, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1252 N 22ND ST UNIT A
Mailing Address - Street 2:
Mailing Address - City:LARAMIE
Mailing Address - State:WY
Mailing Address - Zip Code:82072-5306
Mailing Address - Country:US
Mailing Address - Phone:307-745-5364
Mailing Address - Fax:307-745-4164
Practice Address - Street 1:1252 N 22ND ST UNIT A
Practice Address - Street 2:
Practice Address - City:LARAMIE
Practice Address - State:WY
Practice Address - Zip Code:82072
Practice Address - Country:US
Practice Address - Phone:307-745-5364
Practice Address - Fax:307-745-4164
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-22
Last Update Date:2018-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO102244363LW0102X
WY41390.1753363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health