Provider Demographics
NPI:1346607215
Name:RIEDEL, SELENA (NP)
Entity Type:Individual
Prefix:MRS
First Name:SELENA
Middle Name:
Last Name:RIEDEL
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3857 BIXBY DR
Mailing Address - Street 2:
Mailing Address - City:LA VERNE
Mailing Address - State:CA
Mailing Address - Zip Code:91750-2002
Mailing Address - Country:US
Mailing Address - Phone:909-255-5771
Mailing Address - Fax:909-392-7951
Practice Address - Street 1:3857 BIXBY DR
Practice Address - Street 2:
Practice Address - City:LA VERNE
Practice Address - State:CA
Practice Address - Zip Code:91750-2002
Practice Address - Country:US
Practice Address - Phone:909-255-5771
Practice Address - Fax:909-392-7951
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-24
Last Update Date:2016-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA442799363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily