Healthcare Provider Details

I. General information

NPI: 1104975747
Provider Name (Legal Business Name): SANDRA RIESKE MSN, CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2007
Last Update Date: 07/19/2026
Certification Date: 07/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 RACINE DR STE 350
WILMINGTON NC
28403-8705
US

IV. Provider business mailing address

1130 CRESTFIELD WAY
LELAND NC
28451-9405
US

V. Phone/Fax

Practice location:
  • Phone: 844-854-6884
  • Fax:
Mailing address:
  • Phone: 910-233-7199
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number5006705
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number5006705
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberNP-07477
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: