Provider Demographics
NPI:1134102965
Name:RIVENBURGH-CASILLAS, TAMARA SUE (FNP)
Entity type:Individual
Prefix:MS
First Name:TAMARA
Middle Name:SUE
Last Name:RIVENBURGH-CASILLAS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:TAMARA
Other - Middle Name:SUE
Other - Last Name:RIVENBURGH-CASILLAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:8546 E GLENCOVE ST
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85207-4111
Mailing Address - Country:US
Mailing Address - Phone:480-980-6465
Mailing Address - Fax:
Practice Address - Street 1:1100 S. DOBSON RD
Practice Address - Street 2:#223
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85286
Practice Address - Country:US
Practice Address - Phone:480-821-8888
Practice Address - Fax:480-821-0888
Is Sole Proprietor?:No
Enumeration Date:2005-11-25
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP0528363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily