Basic Information
| Provider Information | |||||||||
| NPI: | 1871510685 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RIEDL | ||||||||
| FirstName: | PATRICIA | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | APNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1531 S MADISON ST | ||||||||
| Address2: | |||||||||
| City: | APPLETON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 54915 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9207304411 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1531 S MADISON ST | ||||||||
| Address2: | |||||||||
| City: | APPLETON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 54915 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9207304411 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/16/2006 | ||||||||
| LastUpdateDate: | 09/09/2008 | ||||||||
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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 | 364SP0809X | 1939033 | WI | Y | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Psych/Mental Health, Adult | 363L00000X | 75770 | WI | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | P00149053 | 01 | RAILROAD MEDICARE | OTHER | P46638 | 01 | CIGNA | OTHER | 47129 | 01 | NETWORK HEALTH PLAN | OTHER | 41196600 | 05 | WI | MEDICAID |