Provider Demographics
NPI:1659624203
Name:RIVERA, CRYSTAL MARIE (LPN)
Entity Type:Individual
Prefix:MS
First Name:CRYSTAL
Middle Name:MARIE
Last Name:RIVERA
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:56 AVIS DR
Mailing Address - Street 2:
Mailing Address - City:HOLBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11741-2515
Mailing Address - Country:US
Mailing Address - Phone:631-413-6252
Mailing Address - Fax:
Practice Address - Street 1:56 AVIS DR
Practice Address - Street 2:
Practice Address - City:HOLBROOK
Practice Address - State:NY
Practice Address - Zip Code:11741-2515
Practice Address - Country:US
Practice Address - Phone:631-413-6252
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-19
Last Update Date:2012-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY311644-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse