Provider Demographics
NPI:1457041816
Name:RIVERA, INGRID MARCELA (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:MRS
First Name:INGRID
Middle Name:MARCELA
Last Name:RIVERA
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 30012
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89173-0012
Mailing Address - Country:US
Mailing Address - Phone:702-372-8994
Mailing Address - Fax:
Practice Address - Street 1:4958 S RAINBOW BLVD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89118-1418
Practice Address - Country:US
Practice Address - Phone:702-372-8994
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-10
Last Update Date:2023-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV867014363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty