Provider Demographics
NPI:1528543204
Name:RIDDICK, IDRIS (LPN)
Entity Type:Individual
Prefix:
First Name:IDRIS
Middle Name:
Last Name:RIDDICK
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3872 WYALUSING AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104-1124
Mailing Address - Country:US
Mailing Address - Phone:610-679-1723
Mailing Address - Fax:
Practice Address - Street 1:3872 WYALUSING AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-1124
Practice Address - Country:US
Practice Address - Phone:610-679-1723
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-28
Last Update Date:2018-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPN308356164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse