Provider Demographics
NPI:1437121712
Name:RISLEY, JULIA LYNNE (PA-C)
Entity Type:Individual
Prefix:
First Name:JULIA
Middle Name:LYNNE
Last Name:RISLEY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JULIA
Other - Middle Name:LYNNE
Other - Last Name:CHICKEDANTZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:5750 COVENTRY LN
Mailing Address - Street 2:SUITE 101
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-7166
Mailing Address - Country:US
Mailing Address - Phone:260-436-9337
Mailing Address - Fax:260-436-9626
Practice Address - Street 1:5750 COVENTRY LN
Practice Address - Street 2:SUITE 101
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-7166
Practice Address - Country:US
Practice Address - Phone:260-436-9337
Practice Address - Fax:260-436-9626
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10000508A363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000301921OtherANTHEM
INP79087Medicare UPIN
IN215960BMedicare ID - Type Unspecified
IN000000301921OtherANTHEM