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General NPI Number Information
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NPI Number | 1528543204
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Entity Type | Individual
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Provider Name | IDRIS RIDDICK LPN
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Gender | Male
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Dates
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Enumeration Date | 09/28/2018
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Last Update Date | 09/28/2018
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Provider Practice Location Address
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Address Line | 3872 WYALUSING AVE
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City | PHILADELPHIA
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State | PA
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Zip | 19104-1124
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Country | US
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Telephone | 610-679-1723
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Fax |
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Provider Business Mailing Address
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Address Line | 3872 WYALUSING AVE
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City | PHILADELPHIA
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State | PA
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Zip | 19104-1124
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Country | US
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Telephone | 610-679-1723
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 164W00000X
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Taxonomy Name | Licensed Practical Nurse
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License Number | PN308356
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License Number State | PA
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