Provider Demographics
NPI:1336922244
Name:RIDDLE, KATHERINE (AGACNP-BC)
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:
Last Name:RIDDLE
Suffix:
Gender:F
Credentials:AGACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 N EAST AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49201-1753
Mailing Address - Country:US
Mailing Address - Phone:517-205-4800
Mailing Address - Fax:517-205-1713
Practice Address - Street 1:15750 NORTHLINE RD
Practice Address - Street 2:
Practice Address - City:SOUTHGATE
Practice Address - State:MI
Practice Address - Zip Code:48195-2378
Practice Address - Country:US
Practice Address - Phone:734-357-0505
Practice Address - Fax:734-357-0506
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-15
Last Update Date:2024-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704318916363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care