Provider Demographics
NPI:1801938394
Name:RIDDLE, KELLI KNOX (PA)
Entity type:Individual
Prefix:
First Name:KELLI
Middle Name:KNOX
Last Name:RIDDLE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1543 PROFESSIONAL PKWY
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:AL
Mailing Address - Zip Code:36830-2858
Mailing Address - Country:US
Mailing Address - Phone:334-821-9308
Mailing Address - Fax:850-522-8354
Practice Address - Street 1:1543 PROFESSIONAL PKWY
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:AL
Practice Address - Zip Code:36830-2858
Practice Address - Country:US
Practice Address - Phone:334-821-9308
Practice Address - Fax:850-522-8354
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2013-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPA440363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL529920250Medicaid
AL009913716Medicaid
AL009913717Medicaid
AL009913716Medicaid
ALJ950Medicare PIN