Provider Demographics
NPI:1467106971
Name:RIDDLE, JASMINE ELYSE (APRN)
Entity Type:Individual
Prefix:
First Name:JASMINE
Middle Name:ELYSE
Last Name:RIDDLE
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:965 RIDGE LAKE BLVD STE 315
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120-9401
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6025 WALNUT GROVE RD STE 301
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38120-2123
Practice Address - Country:US
Practice Address - Phone:901-226-0456
Practice Address - Fax:901-226-0458
Is Sole Proprietor?:No
Enumeration Date:2022-02-04
Last Update Date:2022-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS905311363LA2100X
TN31464363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0000207611OtherTENNESSEE BOARD OF NURSING