Provider Demographics
NPI:1407932361
Name:RILEY, SUSAN B (NP)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:B
Last Name:RILEY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23702 HWY 80 EAST
Mailing Address - Street 2:P.O. BOX 957
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30458
Mailing Address - Country:US
Mailing Address - Phone:912-489-4090
Mailing Address - Fax:
Practice Address - Street 1:23702 HWY 80 EAST
Practice Address - Street 2:
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458
Practice Address - Country:US
Practice Address - Phone:912-489-4090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-31
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAR91268363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00606119BMedicaid
GAR91268Medicare UPIN
GA00606119BMedicaid