Healthcare Provider Details

I. General information

NPI: 1861173312
Provider Name (Legal Business Name): STEPHANIE MARIE RIORDAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2023
Last Update Date: 08/01/2023
Certification Date: 08/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31 NETTLE RD
MORIARTY NM
87035-5336
US

IV. Provider business mailing address

31 NETTLE RD
MORIARTY NM
87035-5336
US

V. Phone/Fax

Practice location:
  • Phone: 407-506-2822
  • Fax:
Mailing address:
  • Phone: 407-506-2822
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number64695
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: