Provider Demographics
NPI:1265487805
Name:RIVERA, LINDA M (NURSE PRACTIONER)
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:M
Last Name:RIVERA
Suffix:
Gender:F
Credentials:NURSE PRACTIONER
Other - Prefix:
Other - First Name:LINDA
Other - Middle Name:M
Other - Last Name:LACKEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:248 MCHENRY ST
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:WI
Mailing Address - Zip Code:53105-1828
Mailing Address - Country:US
Mailing Address - Phone:262-767-8000
Mailing Address - Fax:
Practice Address - Street 1:248 MCHENRY ST
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:WI
Practice Address - Zip Code:53105-1828
Practice Address - Country:US
Practice Address - Phone:262-767-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2023-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI9536363L00000X
IN71002710A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100092592Medicaid
000000388354OtherANTHEM BCBS
11541204OtherCAQH
KY1281626Medicare ID - Type Unspecified