Provider Demographics
NPI:1174734917
Name:RILEY, KATHRYN ANN (RD, LD)
Entity type:Individual
Prefix:MS
First Name:KATHRYN
Middle Name:ANN
Last Name:RILEY
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6447 OAKSHORE DR
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32404-7457
Mailing Address - Country:US
Mailing Address - Phone:850-871-9423
Mailing Address - Fax:
Practice Address - Street 1:597 WEST 11TH STREET
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32401-2330
Practice Address - Country:US
Practice Address - Phone:850-872-4455
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-24
Last Update Date:2008-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND 3566133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU1261ZMedicare ID - Type UnspecifiedLICENSED DIETITIAN