Provider Demographics
NPI:1831588110
Name:RILEY, PETERGAYLE
Entity type:Individual
Prefix:
First Name:PETERGAYLE
Middle Name:
Last Name:RILEY
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 1:13802 QUEENS BLVD
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11435-2647
Mailing Address - Country:US
Mailing Address - Phone:718-206-2000
Mailing Address - Fax:
Practice Address - Street 1:13802 QUEENS BLVD
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11435-2647
Practice Address - Country:US
Practice Address - Phone:718-206-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-09
Last Update Date:2018-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY314000000X
NY302754164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
No314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility