Provider Demographics
NPI:1538439385
Name:RIEDEL, MICCA R (ANP-C, GNP-BC)
Entity type:Individual
Prefix:MRS
First Name:MICCA
Middle Name:R
Last Name:RIEDEL
Suffix:
Gender:F
Credentials:ANP-C, GNP-BC
Other - Prefix:MS
Other - First Name:MICCA
Other - Middle Name:RACHEL
Other - Last Name:ROBERTS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ANP-C GNP-BC
Mailing Address - Street 1:610 STRICKLAND DR STE 130
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:TX
Mailing Address - Zip Code:77630-4788
Mailing Address - Country:US
Mailing Address - Phone:409-291-8710
Mailing Address - Fax:409-247-2105
Practice Address - Street 1:610 STRICKLAND DR STE 130
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:TX
Practice Address - Zip Code:77630-4788
Practice Address - Country:US
Practice Address - Phone:409-291-8710
Practice Address - Fax:409-247-2105
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-11
Last Update Date:2024-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP121473363LG0600X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology