Provider Demographics
NPI:1396203089
Name:RIDDLE, MARISA (CRNA)
Entity Type:Individual
Prefix:
First Name:MARISA
Middle Name:
Last Name:RIDDLE
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:MARISA
Other - Middle Name:
Other - Last Name:RIDDLE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DNP
Mailing Address - Street 1:1514 W BERRIDGE LN
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85015-2057
Mailing Address - Country:US
Mailing Address - Phone:480-209-3175
Mailing Address - Fax:
Practice Address - Street 1:18701 N 67TH AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-7100
Practice Address - Country:US
Practice Address - Phone:623-561-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-12
Last Update Date:2024-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ278016367500000X
AZRN181155163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse