Provider Demographics
NPI:1790893147
Name:RIVERA, ERIN EILEEN (PHD, CNS, APRN, BC)
Entity Type:Individual
Prefix:MRS
First Name:ERIN
Middle Name:EILEEN
Last Name:RIVERA
Suffix:
Gender:F
Credentials:PHD, CNS, APRN, BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 E COOK RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-3636
Mailing Address - Country:US
Mailing Address - Phone:260-489-6030
Mailing Address - Fax:260-489-5536
Practice Address - Street 1:415 E COOK RD
Practice Address - Street 2:SUITE 100
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-3636
Practice Address - Country:US
Practice Address - Phone:260-489-6030
Practice Address - Fax:260-489-5536
Is Sole Proprietor?:No
Enumeration Date:2006-08-27
Last Update Date:2012-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN70000103A364SG0600X, 364S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist
No364SG0600XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201006300Medicaid
IN201006300Medicaid
IN580940EMedicare ID - Type UnspecifiedPROVIDER NUMBER
INM400062057Medicare PIN