Provider Demographics
NPI:1659302545
Name:RILEY, ANTOINETTE R (FNP, DCNP)
Entity Type:Individual
Prefix:
First Name:ANTOINETTE
Middle Name:R
Last Name:RILEY
Suffix:
Gender:F
Credentials:FNP, DCNP
Other - Prefix:
Other - First Name:ANTOINETTE
Other - Middle Name:RENEE
Other - Last Name:POPE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NURSE PRACTITIONER
Mailing Address - Street 1:PO BOX 1326
Mailing Address - Street 2:
Mailing Address - City:MARSHALL
Mailing Address - State:TX
Mailing Address - Zip Code:75671-1326
Mailing Address - Country:US
Mailing Address - Phone:903-927-3782
Mailing Address - Fax:903-927-1764
Practice Address - Street 1:1011 S WILLIAM ST
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:TX
Practice Address - Zip Code:75551-3245
Practice Address - Country:US
Practice Address - Phone:903-796-2868
Practice Address - Fax:903-796-0826
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2023-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX630914363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8G9015Medicare PIN