Provider Demographics
NPI:1093031437
Name:RIVERA, CRISTINA
Entity Type:Individual
Prefix:
First Name:CRISTINA
Middle Name:
Last Name:RIVERA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 BUHL LN
Mailing Address - Street 2:
Mailing Address - City:EAST NORTHPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11731-5215
Mailing Address - Country:US
Mailing Address - Phone:631-766-2169
Mailing Address - Fax:516-934-0788
Practice Address - Street 1:361 BROADWAY
Practice Address - Street 2:
Practice Address - City:BETHPAGE
Practice Address - State:NY
Practice Address - Zip Code:11714-3008
Practice Address - Country:US
Practice Address - Phone:631-766-2169
Practice Address - Fax:516-934-0788
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-09
Last Update Date:2010-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006837-1133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist