Provider Demographics
NPI:1225200066
Name:RIVERA, LISA A (NP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:A
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 1:5268 GODWIN BLVD
Mailing Address - Street 2:
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23434-8114
Mailing Address - Country:US
Mailing Address - Phone:757-255-7117
Mailing Address - Fax:757-255-7139
Practice Address - Street 1:1000 COMMERCIAL LN
Practice Address - Street 2:
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23434-8148
Practice Address - Country:US
Practice Address - Phone:757-942-1025
Practice Address - Fax:757-925-3504
Is Sole Proprietor?:No
Enumeration Date:2008-04-01
Last Update Date:2013-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024167690363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA004945310Medicaid