Provider Demographics
NPI:1386256485
Name:RIESEN, NOELLE KLAWON
Entity type:Individual
Prefix:MS
First Name:NOELLE
Middle Name:KLAWON
Last Name:RIESEN
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:NOELLE
Other - Middle Name:KLAWON
Other - Last Name:MANESE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1555 INDIAN RIVER BLVD STE B210
Mailing Address - Street 2:
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32960-7113
Mailing Address - Country:US
Mailing Address - Phone:772-257-8224
Mailing Address - Fax:772-252-3245
Practice Address - Street 1:12196 COUNTY ROAD 512
Practice Address - Street 2:
Practice Address - City:FELLSMERE
Practice Address - State:FL
Practice Address - Zip Code:32948-5463
Practice Address - Country:US
Practice Address - Phone:772-257-8224
Practice Address - Fax:772-252-3245
Is Sole Proprietor?:No
Enumeration Date:2020-08-19
Last Update Date:2025-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11005813363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLOW686OtherFL HF MEDICARE