Provider Demographics
NPI:1558092627
Name:RIVERA, KATIE SHIRLEY (LPN)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:SHIRLEY
Last Name:RIVERA
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:KATIE
Other - Middle Name:SHIRLEY
Other - Last Name:BISEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:40 AIRPORT RD
Mailing Address - Street 2:
Mailing Address - City:WATERVILLE
Mailing Address - State:ME
Mailing Address - Zip Code:04901-4524
Mailing Address - Country:US
Mailing Address - Phone:207-872-7272
Mailing Address - Fax:207-872-0639
Practice Address - Street 1:40 AIRPORT RD
Practice Address - Street 2:
Practice Address - City:WATERVILLE
Practice Address - State:ME
Practice Address - Zip Code:04901-4524
Practice Address - Country:US
Practice Address - Phone:207-872-7272
Practice Address - Fax:207-872-0639
Is Sole Proprietor?:No
Enumeration Date:2022-06-21
Last Update Date:2022-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELPN14720164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse