Provider Demographics
NPI:1780355420
Name:RIVERA, ISABELLA A
Entity type:Individual
Prefix:
First Name:ISABELLA
Middle Name:A
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 1:1801 9TH AVE S
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33712-2305
Mailing Address - Country:US
Mailing Address - Phone:727-608-6993
Mailing Address - Fax:
Practice Address - Street 1:4731 14TH AVE S
Practice Address - Street 2:
Practice Address - City:SAINT PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33711-2321
Practice Address - Country:US
Practice Address - Phone:727-608-6993
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-22
Last Update Date:2021-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL5201577251C00000X, 164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
No164W00000XNursing Service ProvidersLicensed Practical Nurse