Provider Demographics
NPI:1225112998
Name:RIVERA, MELISSA DAWN
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:DAWN
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:HC 75 BOX 49A
Mailing Address - Street 2:
Mailing Address - City:CHAMA
Mailing Address - State:NM
Mailing Address - Zip Code:87520-9701
Mailing Address - Country:US
Mailing Address - Phone:505-759-7228
Mailing Address - Fax:
Practice Address - Street 1:HC 75 BOX 49A
Practice Address - Street 2:
Practice Address - City:CHAMA
Practice Address - State:NM
Practice Address - Zip Code:87520-9701
Practice Address - Country:US
Practice Address - Phone:505-759-7228
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2008-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
N/A247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM000K3526Medicaid
NMHSZ196OtherMEDICARE PART B
NM320057Medicare Oscar/Certification