Individual
JENTRY DANIELLE RIDDLE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PA
Contact information
Practice address
4204 EAST STAN SCHLEUTER LOOP, KILLEEN, TX 76542-8352
(254) 690-2800
(254) 690-5401
Mailing address
1201 SAM BASS ROAD, ROUND ROCK, TX 78681-4137
(512) 388-1861
(512) 388-0373
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
MP00154600
NJ
363A00000X
Physician Assistant
PA05748
TX
363AM0700X
Medical Physician Assistant
Primary
PA05748
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1991747-01
—
TX
05
—
1991747-02
—
TX
Enumeration date
07/07/2006
Last updated
06/15/2009
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