Provider Demographics
NPI:1114988102
Name:RIVERA, MADELYN (NP)
Entity Type:Individual
Prefix:MS
First Name:MADELYN
Middle Name:
Last Name:RIVERA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 COMMONWEALTH AVE
Mailing Address - Street 2:BOSTON COLLEGE-UNIVERSITY HEALTH SERVICES CUSHING HALL
Mailing Address - City:CHESTNUT HILL
Mailing Address - State:MA
Mailing Address - Zip Code:02467-3800
Mailing Address - Country:US
Mailing Address - Phone:617-552-2659
Mailing Address - Fax:617-552-3603
Practice Address - Street 1:140 COMMONWEALTH AVE
Practice Address - Street 2:BOSTON COLLEGE-UNIVERSITY HEALTH SERVICES CUSHING HALL
Practice Address - City:CHESTNUT HILL
Practice Address - State:MA
Practice Address - Zip Code:02467-3800
Practice Address - Country:US
Practice Address - Phone:617-552-2659
Practice Address - Fax:617-552-3603
Is Sole Proprietor?:No
Enumeration Date:2006-03-29
Last Update Date:2008-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA185072363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0343251Medicaid
MA0343251Medicaid
MAP11200Medicare UPIN