Healthcare Provider Details

I. General information

NPI: 1285359158
Provider Name (Legal Business Name): JESSICA RENEE RILEY AG-ACNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2022
Last Update Date: 05/25/2023
Certification Date: 05/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 SAINT FRANCIS DR
CAPE GIRARDEAU MO
63703-5049
US

IV. Provider business mailing address

1737 EAGLE DR
JACKSON MO
63755-3244
US

V. Phone/Fax

Practice location:
  • Phone: 573-331-3000
  • Fax:
Mailing address:
  • Phone: 573-258-0811
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number2022042296
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number2004019083
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: