Basic Information
| Provider Information | |||||||||
| NPI: | 1053810101 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RILEY | ||||||||
| FirstName: | KRYSTAL | ||||||||
| MiddleName: | N. | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 497 | ||||||||
| Address2: | |||||||||
| City: | AUGUSTA | ||||||||
| State: | AR | ||||||||
| PostalCode: | 720060497 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8703472534 | ||||||||
| FaxNumber: | 8703472023 | ||||||||
| Practice Location | |||||||||
| Address1: | 1500 MUSEUM RD | ||||||||
| Address2: | |||||||||
| City: | CONWAY | ||||||||
| State: | AR | ||||||||
| PostalCode: | 720324785 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5019329010 | ||||||||
| FaxNumber: | 5019320020 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/05/2018 | ||||||||
| LastUpdateDate: | 07/08/2019 | ||||||||
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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 | A005501 | AR | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 224751758 | 05 | AR | MEDICAID |