Healthcare Provider Details

I. General information

NPI: 1093466245
Provider Name (Legal Business Name): RILEY NIEBUHR FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/10/2022
Last Update Date: 11/01/2022
Certification Date: 11/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 W STOUT ST
RICE LAKE WI
54868-5000
US

IV. Provider business mailing address

1700 W STOUT ST
RICE LAKE WI
54868-5000
US

V. Phone/Fax

Practice location:
  • Phone: 715-234-1515
  • Fax:
Mailing address:
  • Phone: 715-236-8100
  • Fax: 715-236-8104

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License Number294802
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number11893
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: