Healthcare Provider Details

I. General information

NPI: 1871071399
Provider Name (Legal Business Name): MARIANNA RILEY FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/06/2018
Last Update Date: 10/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 N STATE ST
JACKSON MS
39216-4500
US

IV. Provider business mailing address

117 INDIAN SUMMER LN
CLINTON MS
39056-4153
US

V. Phone/Fax

Practice location:
  • Phone: 601-506-6641
  • Fax:
Mailing address:
  • Phone: 601-506-6641
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number902493
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: