Provider Demographics
NPI:1982319331
Name:RILEY, VERASTINE
Entity Type:Individual
Prefix:
First Name:VERASTINE
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 1:934 43RD ST
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53140-5703
Mailing Address - Country:US
Mailing Address - Phone:262-721-6485
Mailing Address - Fax:
Practice Address - Street 1:934 43RD ST
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53140-5703
Practice Address - Country:US
Practice Address - Phone:262-721-6485
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-19
Last Update Date:2023-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI00175293104A0625X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness