Provider Demographics
NPI:1154432748
Name:RILEY, PAMELA RAE DEANE (AUD, CCC-A)
Entity type:Individual
Prefix:DR
First Name:PAMELA
Middle Name:RAE DEANE
Last Name:RILEY
Suffix:
Gender:F
Credentials:AUD, CCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:919 E JEFFERSON BLVD STE 104
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-3115
Mailing Address - Country:US
Mailing Address - Phone:574-232-5815
Mailing Address - Fax:574-289-4327
Practice Address - Street 1:919 E JEFFERSON BLVD STE 104
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46617-3115
Practice Address - Country:US
Practice Address - Phone:574-232-5815
Practice Address - Fax:574-289-4327
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN23002137A237600000X
MI3501002824237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000247031OtherANTHEM PROVIDER
IN968550BMedicare ID - Type UnspecifiedMEDICARE PROVIDER
IN000000247031OtherANTHEM PROVIDER