MEDICARE: TAYLOR RIDDELL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LA2100X	Acute Care Nurse Practitioner	1111962	TX
2	363LA2100X	Acute Care Nurse Practitioner	873008	TX

General Provider Information

NPI Number	:	1164122255
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TAYLOR RIDDELL

Provider Business Mailing Address
First Line	:	4317 CEDAR SPRINGS RD APT C
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75219-6634
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	8210 MID CITIES BLVD STE 120
Second Line	:
City	:	NORTH RICHLAND HILLS
State	:	TX
Zip	:	76180-4701
Country	:	US
Telephone Number	:	817-969-6030
Fax Number	:	817-969-6039

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/07/2023
Last Update Date	:	10/06/2023

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Directions to “ TAYLOR RIDDELL ” Practice Location

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