Provider Demographics
NPI:1568848299
Name:RILEY, MARY (CNP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:RILEY
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 374
Mailing Address - Street 2:
Mailing Address - City:RULEVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38771-0374
Mailing Address - Country:US
Mailing Address - Phone:662-588-5614
Mailing Address - Fax:
Practice Address - Street 1:1502 S COLORADO ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:MS
Practice Address - Zip Code:38703-7219
Practice Address - Country:US
Practice Address - Phone:662-334-6448
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-04
Last Update Date:2015-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR882123363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner