Provider Demographics
NPI:1295157634
Name:RILEY, SHAUNDRA (WHNP-BC, FNP-BC,ENP)
Entity type:Individual
Prefix:MRS
First Name:SHAUNDRA
Middle Name:
Last Name:RILEY
Suffix:
Gender:F
Credentials:WHNP-BC, FNP-BC,ENP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4300 MARKET PTE DR STE 100
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55435-5435
Mailing Address - Country:US
Mailing Address - Phone:925-767-4574
Mailing Address - Fax:
Practice Address - Street 1:4300 MARKET PTE DR STE 100
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55435-5435
Practice Address - Country:US
Practice Address - Phone:925-767-4574
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-18
Last Update Date:2025-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016036656363LF0000X
KS53-76188-122363LF0000X, 363LW0102X
MO2013034497363LW0102X
MN6711363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health