Provider Demographics
NPI:1609486943
Name:RIVERO FUNDORA, LILIAM (ARNP)
Entity Type:Individual
Prefix:
First Name:LILIAM
Middle Name:
Last Name:RIVERO FUNDORA
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13885 SW 260TH ST
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33032-6722
Mailing Address - Country:US
Mailing Address - Phone:786-675-0722
Mailing Address - Fax:
Practice Address - Street 1:13885 SW 260TH ST
Practice Address - Street 2:
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33032-6722
Practice Address - Country:US
Practice Address - Phone:786-675-0722
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-02
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11008302363LP0808X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health