Provider Demographics
NPI:1710123237
Name:RIVINIUS, LYNETTE J (RN, MS, CNS, CDE)
Entity Type:Individual
Prefix:MRS
First Name:LYNETTE
Middle Name:J
Last Name:RIVINIUS
Suffix:
Gender:F
Credentials:RN, MS, CNS, CDE
Other - Prefix:MISS
Other - First Name:LYNETTE
Other - Middle Name:JOYCE
Other - Last Name:FLEMMER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN, MS
Mailing Address - Street 1:22552 LARK ST
Mailing Address - Street 2:
Mailing Address - City:GRAND TERRACE
Mailing Address - State:CA
Mailing Address - Zip Code:92313-5716
Mailing Address - Country:US
Mailing Address - Phone:909-380-4397
Mailing Address - Fax:
Practice Address - Street 1:22552 LARK ST
Practice Address - Street 2:
Practice Address - City:GRAND TERRACE
Practice Address - State:CA
Practice Address - Zip Code:92313-5716
Practice Address - Country:US
Practice Address - Phone:909-380-4397
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-06
Last Update Date:2009-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA260455163WD0400X
CA1318364S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist
No163WD0400XNursing Service ProvidersRegistered NurseDiabetes Educator