Provider Demographics
NPI:1326748856
Name:RIVERA ORTIZ, MARISOL
Entity Type:Individual
Prefix:MS
First Name:MARISOL
Middle Name:
Last Name:RIVERA ORTIZ
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:MARISOL
Other - Middle Name:
Other - Last Name:RIVER ORTIZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6171 DUNSMORE CANYON LN
Mailing Address - Street 2:
Mailing Address - City:PORTER
Mailing Address - State:TX
Mailing Address - Zip Code:77365-7189
Mailing Address - Country:US
Mailing Address - Phone:863-263-5145
Mailing Address - Fax:
Practice Address - Street 1:6171 DUNSMORE CANYON LN
Practice Address - Street 2:
Practice Address - City:PORTER
Practice Address - State:TX
Practice Address - Zip Code:77365-7189
Practice Address - Country:US
Practice Address - Phone:863-263-5145
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-03
Last Update Date:2023-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9521298163WE0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WE0003XNursing Service ProvidersRegistered NurseEmergency
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL9521298Medicaid