Provider Demographics
NPI:1477005007
Name:RIDDLE, AMIE WOLVERTON (PMHNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:AMIE
Middle Name:WOLVERTON
Last Name:RIDDLE
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6320 SOUTHWEST BLVD
Mailing Address - Street 2:SUITE 207
Mailing Address - City:BENBROOK
Mailing Address - State:TX
Mailing Address - Zip Code:76109-6965
Mailing Address - Country:US
Mailing Address - Phone:817-735-4430
Mailing Address - Fax:
Practice Address - Street 1:320 SILVER CANYON DR
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76108-9612
Practice Address - Country:US
Practice Address - Phone:817-734-7981
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-31
Last Update Date:2016-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP132445363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health