Provider Demographics
NPI:1720784796
Name:RIVERA, ALYSSA
Entity Type:Individual
Prefix:
First Name:ALYSSA
Middle Name:
Last Name:RIVERA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 E RIDGEWOOD AVE
Mailing Address - Street 2:SUITE 208
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07450
Mailing Address - Country:US
Mailing Address - Phone:201-444-0868
Mailing Address - Fax:201-493-0797
Practice Address - Street 1:1200 E RIDGEWOOD AVE
Practice Address - Street 2:SUITE 208
Practice Address - City:RIDGEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07450
Practice Address - Country:US
Practice Address - Phone:201-444-0868
Practice Address - Fax:201-493-0797
Is Sole Proprietor?:No
Enumeration Date:2023-02-01
Last Update Date:2023-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJF12220228363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner