Provider Demographics
NPI:1952947574
Name:MWANGI-RILEY, TERESIAH W
Entity Type:Individual
Prefix:
First Name:TERESIAH
Middle Name:W
Last Name:MWANGI-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 1:1418 CATHERWOOD DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46614-2836
Mailing Address - Country:US
Mailing Address - Phone:574-261-3450
Mailing Address - Fax:
Practice Address - Street 1:3100 WINDSOR CT
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46514-5556
Practice Address - Country:US
Practice Address - Phone:574-266-6555
Practice Address - Fax:574-266-6888
Is Sole Proprietor?:No
Enumeration Date:2019-11-19
Last Update Date:2019-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71009551A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner