Provider Demographics
NPI:1851374318
Name:RICKLEY, RICHARD EARL JR
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:EARL
Last Name:RICKLEY
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1060 GAFFNEY ROAD #7440
Mailing Address - Street 2:COMMANDER, USA-MEDDAC-AK, ATTN: MCUC-MMD-QM
Mailing Address - City:FT. WAINWRIGHT
Mailing Address - State:AK
Mailing Address - Zip Code:99703-4845
Mailing Address - Country:US
Mailing Address - Phone:907-353-5418
Mailing Address - Fax:907-353-4845
Practice Address - Street 1:1060 GAFFNEY ROAD #7440
Practice Address - Street 2:COMMANDER, USA-MEDDAC-AK, ATTN: MCUC-MMD-QM
Practice Address - City:FT. WAINWRIGHT
Practice Address - State:AK
Practice Address - Zip Code:99703-4845
Practice Address - Country:US
Practice Address - Phone:907-353-5418
Practice Address - Fax:907-353-4845
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN527259L163W00000X
AK25011163W00000X
MDR150185163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse