Healthcare Provider Details

I. General information

NPI: 1144469073
Provider Name (Legal Business Name): JESSICA ALICIA RILEY APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/17/2009
Last Update Date: 08/20/2021
Certification Date: 11/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5003 OGG RD
CEDAR HILL TN
37032-4826
US

IV. Provider business mailing address

5003 OGG RD
CEDAR HILL TN
37032-4826
US

V. Phone/Fax

Practice location:
  • Phone: 808-212-8470
  • Fax:
Mailing address:
  • Phone: 808-212-8470
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License Number716812
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number3016337
License Number StateKY
# 3
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number29844
License Number StateTN
# 4
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number196671
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: