Healthcare Provider Details

I. General information

NPI: 1093638603
Provider Name (Legal Business Name): NICOLE RENEE HARRIS CPRS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: NICOLE RENEE RILEY

II. Dates (important events)

Enumeration Date: 07/31/2026
Last Update Date: 07/31/2026
Certification Date: 07/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4474 HARBISON ST
DAYTON OH
45439-2750
US

IV. Provider business mailing address

4474 HARBISON ST
DAYTON OH
45439-2750
US

V. Phone/Fax

Practice location:
  • Phone: 937-212-7954
  • Fax:
Mailing address:
  • Phone: 937-212-7954
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberPRS.008137
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: