=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538439385
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICCA R RIEDEL ANP-C, GNP-BC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/11/2012
-----------------------------------------------------
Last Update Date | 08/13/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 610 STRICKLAND DR STE 130
-----------------------------------------------------
City | ORANGE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77630-4788
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 409-291-8710
-----------------------------------------------------
Fax | 409-247-2105
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 610 STRICKLAND DR STE 130
-----------------------------------------------------
City | ORANGE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77630-4788
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 409-291-8710
-----------------------------------------------------
Fax | 409-247-2105
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LG0600X
-----------------------------------------------------
Taxonomy Name | Gerontology Nurse Practitioner
-----------------------------------------------------
License Number | AP121473
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LA2200X
-----------------------------------------------------
Taxonomy Name | Adult Health Nurse Practitioner
-----------------------------------------------------
License Number | AP121473
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------