Provider Demographics
NPI:1417625187
Name:RIVERA, STACY MARIE (AG-ACNP)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:MARIE
Last Name:RIVERA
Suffix:
Gender:F
Credentials:AG-ACNP
Other - Prefix:
Other - First Name:STACY
Other - Middle Name:MARIE
Other - Last Name:TORRES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:AG-ACNP
Mailing Address - Street 1:7318 DRAPER AVE
Mailing Address - Street 2:
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-5023
Mailing Address - Country:US
Mailing Address - Phone:352-474-9363
Mailing Address - Fax:
Practice Address - Street 1:286 EUCLID AVE STE 110
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92114-3611
Practice Address - Country:US
Practice Address - Phone:619-416-3510
Practice Address - Fax:619-243-3216
Is Sole Proprietor?:No
Enumeration Date:2021-08-30
Last Update Date:2021-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95011538363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care