Provider Demographics
NPI:1467769612
Name:RILEY, SHERRY LYNN (ARNP)
Entity Type:Individual
Prefix:MS
First Name:SHERRY
Middle Name:LYNN
Last Name:RILEY
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:SHERRY
Other - Middle Name:LYNN
Other - Last Name:PENROD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ARNP
Mailing Address - Street 1:3300 DAIRY RD
Mailing Address - Street 2:
Mailing Address - City:TITUSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32796-1512
Mailing Address - Country:US
Mailing Address - Phone:321-269-6530
Mailing Address - Fax:
Practice Address - Street 1:3300 DAIRY RD
Practice Address - Street 2:
Practice Address - City:TITUSVILLE
Practice Address - State:FL
Practice Address - Zip Code:32796-1512
Practice Address - Country:US
Practice Address - Phone:321-269-6530
Practice Address - Fax:321-269-2334
Is Sole Proprietor?:No
Enumeration Date:2010-09-09
Last Update Date:2018-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP2741782363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL004505000Medicaid
FL004505000Medicaid