Provider Demographics
NPI:1124995147
Name:RILES, TANISHA SHUANTE
Entity type:Individual
Prefix:
First Name:TANISHA
Middle Name:SHUANTE
Last Name:RILES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:702 VAN STREAT HWY
Mailing Address - Street 2:
Mailing Address - City:NICHOLLS
Mailing Address - State:GA
Mailing Address - Zip Code:31554-4017
Mailing Address - Country:US
Mailing Address - Phone:912-501-4094
Mailing Address - Fax:708-367-6703
Practice Address - Street 1:702 VAN STREAT HWY
Practice Address - Street 2:
Practice Address - City:NICHOLLS
Practice Address - State:GA
Practice Address - Zip Code:31554-4017
Practice Address - Country:US
Practice Address - Phone:912-501-4094
Practice Address - Fax:708-367-6703
Is Sole Proprietor?:Yes
Enumeration Date:2025-10-22
Last Update Date:2025-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory