Provider Demographics
NPI:1114918786
Name:RIVERA, SUSAN D (FNP-BC)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:D
Last Name:RIVERA
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:D
Other - Last Name:COX
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:703 VIRGINIA ST
Mailing Address - Street 2:
Mailing Address - City:DUNEDIN
Mailing Address - State:FL
Mailing Address - Zip Code:34698-6615
Mailing Address - Country:US
Mailing Address - Phone:727-734-4000
Mailing Address - Fax:727-738-5037
Practice Address - Street 1:703 VIRGINIA ST
Practice Address - Street 2:
Practice Address - City:DUNEDIN
Practice Address - State:FL
Practice Address - Zip Code:34698-6615
Practice Address - Country:US
Practice Address - Phone:727-734-4000
Practice Address - Fax:727-738-5037
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2016-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9415507363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
INCJ8803OtherGROUP RR MEDICARE
FL016093400Medicaid
INP00146163OtherRR MEDICARE
IN000000111033OtherGROUP ANTHEM
IN000000368986OtherANTHEM
FL02PZHOtherBCBS
IN200471680Medicaid
IN200471680Medicaid
FLIJ801ZMedicare PIN
IN000000111033OtherGROUP ANTHEM