Provider Demographics
NPI:1780912576
Name:RIVERA, JACQUELINE ANGELA (LPN)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:ANGELA
Last Name:RIVERA
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3453 W 60TH ST
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44102
Mailing Address - Country:US
Mailing Address - Phone:216-254-0256
Mailing Address - Fax:216-281-4292
Practice Address - Street 1:3453 W 60TH ST
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44102-5530
Practice Address - Country:US
Practice Address - Phone:216-254-0256
Practice Address - Fax:216-281-4292
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-07
Last Update Date:2009-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN088303164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse