Provider Demographics
NPI:1467865642
Name:RIVERA, LORRIE
Entity Type:Individual
Prefix:
First Name:LORRIE
Middle Name:
Last Name:RIVERA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:814 ROGERS AVE NW
Mailing Address - Street 2:
Mailing Address - City:LIVE OAK
Mailing Address - State:FL
Mailing Address - Zip Code:32064-1781
Mailing Address - Country:US
Mailing Address - Phone:352-318-3694
Mailing Address - Fax:
Practice Address - Street 1:814 ROGERS AVE NW
Practice Address - Street 2:
Practice Address - City:LIVE OAK
Practice Address - State:FL
Practice Address - Zip Code:32064-1781
Practice Address - Country:US
Practice Address - Phone:352-318-3694
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-05
Last Update Date:2014-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL120268376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide