Provider Demographics
NPI:1891374203
Name:RIVERA, MARY GRACE TOLENTINO (APRN)
Entity Type:Individual
Prefix:
First Name:MARY GRACE
Middle Name:TOLENTINO
Last Name:RIVERA
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10170 W TROPICANA AVE # 156-336
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89147-8465
Mailing Address - Country:US
Mailing Address - Phone:702-853-3853
Mailing Address - Fax:702-853-3854
Practice Address - Street 1:5320 S RAINBOW BLVD STE 154
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89118-1807
Practice Address - Country:US
Practice Address - Phone:702-853-3853
Practice Address - Fax:702-853-3854
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-04
Last Update Date:2021-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV838958363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily