Healthcare Provider Details

I. General information

NPI: 1366366460
Provider Name (Legal Business Name): MRS. TYRINDA LANESE RILEY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/10/2026
Last Update Date: 08/10/2026
Certification Date: 08/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12052 N SHORE DR
RESTON VA
20190-4969
US

IV. Provider business mailing address

12052 N SHORE DR
RESTON VA
20190-4969
US

V. Phone/Fax

Practice location:
  • Phone: 865-392-2824
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number0131003164
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: