1033984554 NPI number — KATHLEEN MARIE RIORDAN FNP

Table of content: KATHLEEN MARIE RIORDAN FNP (NPI 1033984554)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033984554 NPI number — KATHLEEN MARIE RIORDAN FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RIORDAN
Provider First Name:
KATHLEEN
Provider Middle Name:
MARIE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
FNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1033984554
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/13/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2570 NW EDENBOWER BLVD STE 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROSEBURG
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97471-6214
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-677-7200
Provider Business Mailing Address Fax Number:
541-229-3309

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
249 DAKOTA ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SUTHERLIN
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97479-9908
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-677-7200
Provider Business Practice Location Address Fax Number:
541-229-3309
Provider Enumeration Date:
11/15/2023

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  7923124-4405 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: 10034451 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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