Healthcare Provider Details

I. General information

NPI: 1013660794
Provider Name (Legal Business Name): TRICIA A RIDDLE FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TRICIA ANN RUSSELL

II. Dates (important events)

Enumeration Date: 02/01/2022
Last Update Date: 05/22/2023
Certification Date: 05/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

514 SE PORT ST LUCIE BLVD
PORT ST LUCIE FL
34984-5108
US

IV. Provider business mailing address

514 SE PORT ST LUCIE BLVD
PORT ST LUCIE FL
34984-5108
US

V. Phone/Fax

Practice location:
  • Phone: 772-871-5900
  • Fax:
Mailing address:
  • Phone: 772-871-5900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number11017304
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: