Healthcare Provider Details

I. General information

NPI: 1649722562
Provider Name (Legal Business Name): MARY RILEY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2016
Last Update Date: 11/05/2021
Certification Date: 11/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4348 ELECTRIC RD
ROANOKE VA
24018-0720
US

IV. Provider business mailing address

1030 S JEFFERSON ST STE 201
ROANOKE VA
24016-4418
US

V. Phone/Fax

Practice location:
  • Phone: 540-769-0976
  • Fax: 540-857-5386
Mailing address:
  • Phone: 540-224-4520
  • Fax: 540-342-1649

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberR218970
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number0024175894
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: