Provider Demographics
NPI:1720056518
Name:RILEY, NICOLE E (NNP)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:E
Last Name:RILEY
Suffix:
Gender:F
Credentials:NNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14223 ARBRE LN N
Mailing Address - Street 2:
Mailing Address - City:HUGO
Mailing Address - State:MN
Mailing Address - Zip Code:55038-4449
Mailing Address - Country:US
Mailing Address - Phone:651-232-7831
Mailing Address - Fax:651-232-7826
Practice Address - Street 1:14223 ARBRE LN N
Practice Address - Street 2:
Practice Address - City:HUGO
Practice Address - State:MN
Practice Address - Zip Code:55038-4449
Practice Address - Country:US
Practice Address - Phone:651-232-7831
Practice Address - Fax:651-232-7826
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR146084-3363LN0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNQ01937Medicare UPIN