Provider Demographics
NPI:1881159325
Name:RIDDLE, MICHELLE RENEE
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:RENEE
Last Name:RIDDLE
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 1:1157 CRANBERRY ST
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:MN
Mailing Address - Zip Code:56307-4518
Mailing Address - Country:US
Mailing Address - Phone:320-828-0698
Mailing Address - Fax:
Practice Address - Street 1:AZ - 86
Practice Address - Street 2:
Practice Address - City:SELLS
Practice Address - State:AZ
Practice Address - Zip Code:85634
Practice Address - Country:US
Practice Address - Phone:520-383-7251
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-08
Last Update Date:2019-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ219771163WM0705X
MN1645655163WM0705X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical