Provider Demographics
NPI:1285848077
Name:RILEY, MATTIE ANN (LPN)
Entity type:Individual
Prefix:MS
First Name:MATTIE
Middle Name:ANN
Last Name:RILEY
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5322 CHANDLER RD
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39305-9750
Mailing Address - Country:US
Mailing Address - Phone:601-483-0046
Mailing Address - Fax:
Practice Address - Street 1:6351 BROWN HOOKE RD
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39305-8994
Practice Address - Country:US
Practice Address - Phone:601-737-5121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSP118958164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00770132Medicaid