Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LC1500X | Nurse Practitioner - Community Health | 209005275 | IL |
NPI | 1033382213 |
---|---|
Provider Name | Gwendolyn R Riddell |
First Address | Santa Rosa, CA 95401-5426 |
Second Address | Santa Rosa, CA 95407-6793 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 08/04/2008 |
Last Update Date | 04/06/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
MR1235438 | DEA (01) | IL |