Provider Demographics
NPI:1841538030
Name:RILEY, AMBER S (CNP)
Entity type:Individual
Prefix:
First Name:AMBER
Middle Name:S
Last Name:RILEY
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10330 ROAD 375
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:MS
Mailing Address - Zip Code:39350-3249
Mailing Address - Country:US
Mailing Address - Phone:601-656-0226
Mailing Address - Fax:601-389-6759
Practice Address - Street 1:10330 ROAD 375
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:MS
Practice Address - Zip Code:39350-3249
Practice Address - Country:US
Practice Address - Phone:601-656-0226
Practice Address - Fax:601-389-6759
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-22
Last Update Date:2015-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR877207363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00050524Medicaid