Provider Demographics
NPI:1871263129
Name:RILEY, DALLAS JOY (FNP-C)
Entity Type:Individual
Prefix:
First Name:DALLAS
Middle Name:JOY
Last Name:RILEY
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SHICKSHINNY
Mailing Address - State:PA
Mailing Address - Zip Code:18655-1221
Mailing Address - Country:US
Mailing Address - Phone:570-841-2292
Mailing Address - Fax:
Practice Address - Street 1:109 S MAIN ST
Practice Address - Street 2:
Practice Address - City:SHICKSHINNY
Practice Address - State:PA
Practice Address - Zip Code:18655-1221
Practice Address - Country:US
Practice Address - Phone:570-542-4094
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-17
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN678772207Q00000X
PASP024564363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine