Provider Demographics
NPI:1659735645
Name:RILEY, LATRICIA SANDAU (APRN)
Entity Type:Individual
Prefix:
First Name:LATRICIA
Middle Name:SANDAU
Last Name:RILEY
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:615-7TH AVENUE
Mailing Address - Street 2:PO BOX 1177
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42102-1177
Mailing Address - Country:US
Mailing Address - Phone:270-783-3573
Mailing Address - Fax:
Practice Address - Street 1:615 7TH AVE
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42101-6921
Practice Address - Country:US
Practice Address - Phone:270-783-3573
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-06
Last Update Date:2016-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3010223363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100410770Medicaid
KY7100410770Medicaid