Provider Demographics
NPI:1881742070
Name:RILEY, STACY LYNNETTE (OD)
Entity type:Individual
Prefix:DR
First Name:STACY
Middle Name:LYNNETTE
Last Name:RILEY
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1950 OLD GALLOWS RD STE 520
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3970
Mailing Address - Country:US
Mailing Address - Phone:703-847-8899
Mailing Address - Fax:571-223-6780
Practice Address - Street 1:15530 E BRONCOS PKWY
Practice Address - Street 2:SUITE 200
Practice Address - City:CENTENNIAL
Practice Address - State:CO
Practice Address - Zip Code:80112-7111
Practice Address - Country:US
Practice Address - Phone:303-766-2020
Practice Address - Fax:303-680-8337
Is Sole Proprietor?:No
Enumeration Date:2007-01-06
Last Update Date:2021-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO99183099152W00000X
COOPT.0001830152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO08183097Medicaid
COU65574Medicare UPIN
CO08183097Medicaid