MEDICARE: PAMELA RENEE RIDDLE BS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171M00000X	Case Manager/Care Coordinator

General Provider Information

NPI Number	:	1467681916
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PAMELA RENEE RIDDLE BS

Provider Business Mailing Address
First Line	:	9802 E NORTHSHIRE
Second Line	:
City	:	CLAREMORE
State	:	OK
Zip	:	74017-1494
Country	:	US
Telephone Number	:	918-899-5291
Fax Number	:

Provider Business Practice Location Address
First Line	:	2 S COO Y YAH ST # 4
Second Line	:
City	:	PRYOR
State	:	OK
Zip	:	74361-4636
Country	:	US
Telephone Number	:	918-824-1310
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/06/2009
Last Update Date	:	07/09/2014

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