Provider Demographics
NPI:1558783746
Name:RIYANTO, MARY SUSAN (WHNP)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:SUSAN
Last Name:RIYANTO
Suffix:
Gender:F
Credentials:WHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5200 HARRY HINES BLVD
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75235-7709
Mailing Address - Country:US
Mailing Address - Phone:469-419-1342
Mailing Address - Fax:
Practice Address - Street 1:6300 HARRY HINES BLVD.
Practice Address - Street 2:SUITE 600
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75235
Practice Address - Country:US
Practice Address - Phone:214-266-0130
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-08
Last Update Date:2022-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX666550363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health