Healthcare Provider Details

I. General information

NPI: 1346950383
Provider Name (Legal Business Name): RILEY EBENROTH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/30/2022
Last Update Date: 11/30/2022
Certification Date: 11/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5198 LITTLE SHIP ST
OSAGE BEACH MO
65065-2863
US

IV. Provider business mailing address

5198 LITTLE SHIP ST
OSAGE BEACH MO
65065-2863
US

V. Phone/Fax

Practice location:
  • Phone: 314-348-0852
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number2020018799
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: