Provider Demographics
NPI:1144281130
Name:RIESS, TAMARA L (NP)
Entity type:Individual
Prefix:MRS
First Name:TAMARA
Middle Name:L
Last Name:RIESS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:710 N NILES AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-1924
Mailing Address - Country:US
Mailing Address - Phone:574-647-1610
Mailing Address - Fax:574-237-6069
Practice Address - Street 1:6913 N MAIN ST
Practice Address - Street 2:
Practice Address - City:GRANGER
Practice Address - State:IN
Practice Address - Zip Code:46530
Practice Address - Country:US
Practice Address - Phone:574-647-1550
Practice Address - Fax:574-243-4306
Is Sole Proprietor?:No
Enumeration Date:2006-03-29
Last Update Date:2021-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71006906A363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
INMI7204009OtherMEDICARE PTAN
IN169380073OtherMEDICARE PTAN
IN236040211OtherMEDICARE PTAN
IN167490001OtherMEDICARE PTAN
IN300001317Medicaid