MEDICARE: MARY KATHRYN RILEY RN, FNP

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	163W00000X	Registered Nurse	188898	TN
2	363L00000X	Nurse Practitioner	30228	TN

General Provider Information

NPI Number	:	1861166191
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY KATHRYN RILEY RN, FNP

Provider Business Mailing Address
First Line	:	371 N PARKWAY STE 400
Second Line	:
City	:	JACKSON
State	:	TN
Zip	:	38305-2891
Country	:	US
Telephone Number	:	731-664-0002
Fax Number	:	731-664-7859

Provider Business Practice Location Address
First Line	:	1022 GREYSTONE SQ
Second Line	:
City	:	JACKSON
State	:	TN
Zip	:	38305-3580
Country	:	US
Telephone Number	:	731-300-2001
Fax Number	:	731-240-8095

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

Provider Enumeration Date	:	08/02/2021
Last Update Date	:	09/03/2021

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