Provider Demographics
NPI:1245852631
Name:RIVERA, LISA J (APN)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:J
Last Name:RIVERA
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9275 MEDICAL PLAZA DR STE F
Mailing Address - Street 2:
Mailing Address - City:NORTH CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29406-9140
Mailing Address - Country:US
Mailing Address - Phone:803-767-4465
Mailing Address - Fax:803-767-4120
Practice Address - Street 1:176 MCSWAIN DR
Practice Address - Street 2:
Practice Address - City:WEST COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29169-4825
Practice Address - Country:US
Practice Address - Phone:803-767-4465
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-08
Last Update Date:2022-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ01032600363LF0000X
SC25651363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily