Provider Demographics
NPI:1366012858
Name:RIEDERER, NICOLE (CRNA)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:RIEDERER
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22928 SE 406TH ST
Mailing Address - Street 2:
Mailing Address - City:ENUMCLAW
Mailing Address - State:WA
Mailing Address - Zip Code:98022-9024
Mailing Address - Country:US
Mailing Address - Phone:253-569-4148
Mailing Address - Fax:
Practice Address - Street 1:1700 13TH ST
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201-1689
Practice Address - Country:US
Practice Address - Phone:253-569-2019
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-28
Last Update Date:2023-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR242050163W00000X
MD143870367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse