Healthcare Provider Details

I. General information

NPI: 1386555159
Provider Name (Legal Business Name): LORA RILEY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2026
Last Update Date: 09/12/2026
Certification Date: 09/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4250 HOSPITAL DR
MARIANNA FL
32446-1917
US

IV. Provider business mailing address

20765 NE DAN PARRISH RD
BLOUNTSTOWN FL
32424-4714
US

V. Phone/Fax

Practice location:
  • Phone: 850-526-2200
  • Fax:
Mailing address:
  • Phone: 850-447-4744
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number9392881
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: