Provider Demographics
NPI:1124503776
Name:RILEY, RANDAL ANTHONY JR (LPN)
Entity type:Individual
Prefix:MR
First Name:RANDAL
Middle Name:ANTHONY
Last Name:RILEY
Suffix:JR
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5826 W BOEHLKE AVE APT 4
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53223-5292
Mailing Address - Country:US
Mailing Address - Phone:305-978-2335
Mailing Address - Fax:
Practice Address - Street 1:4363 W DEAN RD APT 164
Practice Address - Street 2:
Practice Address - City:BROWN DEER
Practice Address - State:WI
Practice Address - Zip Code:53223-3100
Practice Address - Country:US
Practice Address - Phone:305-978-2335
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-29
Last Update Date:2020-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI321568164W00000X
WI252849-30163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No164W00000XNursing Service ProvidersLicensed Practical Nurse