Basic Information
| Provider Information | |||||||||
| NPI: | 1013975523 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RILEY | ||||||||
| FirstName: | SHIELA | ||||||||
| MiddleName: | DIANNE | ||||||||
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| Credential: | ARNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6756 N 4435 | ||||||||
| Address2: | |||||||||
| City: | STRANG | ||||||||
| State: | OK | ||||||||
| PostalCode: | 74367 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9187827744 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | ONE CHOCTAW WAY | ||||||||
| Address2: | |||||||||
| City: | TALIHINA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 74571 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9185677000 | ||||||||
| FaxNumber: | 9185677113 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2006 | ||||||||
| LastUpdateDate: | 07/05/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | R0058301 | OK | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 17R5830 | 05 | OK | MEDICAID |