Provider Demographics
NPI:1235705336
Name:RIVERA, LISA LOUISE (CM61165804)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:LOUISE
Last Name:RIVERA
Suffix:
Gender:F
Credentials:CM61165804
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1314 BROWNE AVE APT 9
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98902-3054
Mailing Address - Country:US
Mailing Address - Phone:509-881-5307
Mailing Address - Fax:
Practice Address - Street 1:201 HIGHLAND DR
Practice Address - Street 2:
Practice Address - City:BUENA
Practice Address - State:WA
Practice Address - Zip Code:98921-0139
Practice Address - Country:US
Practice Address - Phone:509-865-6705
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-28
Last Update Date:2021-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACM611658042470A2800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2470A2800XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Health InformationAssistant Record Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA91-0755984Medicaid