Provider Demographics
NPI:1215472659
Name:RILEY, CHANTRELL
Entity type:Individual
Prefix:
First Name:CHANTRELL
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 1:7211 RHODE ISLAND DR E
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32209-1112
Mailing Address - Country:US
Mailing Address - Phone:904-414-0364
Mailing Address - Fax:
Practice Address - Street 1:7211 RHODE ISLAND DR E
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32209-1112
Practice Address - Country:US
Practice Address - Phone:904-414-0364
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-20
Last Update Date:2016-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9372974163W00000X, 163WC0400X, 163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WC0400XNursing Service ProvidersRegistered NurseCase Management
No163WC1500XNursing Service ProvidersRegistered NurseCommunity Health