Provider Demographics
NPI:1558442061
Name:RIVERA, PAMELA JEAN (PMHNP)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:JEAN
Last Name:RIVERA
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 CRATER LAKE AVE
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-7444
Mailing Address - Country:US
Mailing Address - Phone:541-770-5100
Mailing Address - Fax:541-770-5070
Practice Address - Street 1:15 CRATER LAKE AVE
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-7444
Practice Address - Country:US
Practice Address - Phone:541-770-5100
Practice Address - Fax:541-770-5070
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-18
Last Update Date:2019-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200650041NP363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR200650041NPOtherSTATE NP LICENSE