Provider Demographics
NPI:1083360630
Name:MESA RIVERO, RENNY DE LA CARIDAD
Entity Type:Individual
Prefix:
First Name:RENNY
Middle Name:DE LA CARIDAD
Last Name:MESA RIVERO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1048 SE 24TH AVE
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33035-2140
Mailing Address - Country:US
Mailing Address - Phone:786-368-8121
Mailing Address - Fax:
Practice Address - Street 1:26085 S DIXIE HWY
Practice Address - Street 2:
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33032-6613
Practice Address - Country:US
Practice Address - Phone:305-685-5688
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-22
Last Update Date:2022-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11016707363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily