Basic Information
| Provider Information | |||||||||
| NPI: | 1881873388 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RILEY | ||||||||
| FirstName: | ANDREA | ||||||||
| MiddleName: | ARTA | ||||||||
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| Credential: | CNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1213 24TH ST | ||||||||
| Address2: | STE 100 | ||||||||
| City: | ANACORTES | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982212595 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5755428384 | ||||||||
| FaxNumber: | 5755428387 | ||||||||
| Practice Location | |||||||||
| Address1: | 530 DEMOSS STREET | ||||||||
| Address2: | |||||||||
| City: | LORDSBURG | ||||||||
| State: | NM | ||||||||
| PostalCode: | 880452618 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5755428384 | ||||||||
| FaxNumber: | 5755428387 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2007 | ||||||||
| LastUpdateDate: | 04/30/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WD0400X | LD0681 | NM | N | Nursing Service Providers | Registered Nurse | Diabetes Educator | 363L00000X | AP60134099 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 163W00000X | R62680 | NM | N | Nursing Service Providers | Registered Nurse |
ID Information
| ID | Type | State | Issuer | Description | 81775768 | 05 | NM | MEDICAID |