Provider Demographics
NPI:1831566355
Name:RIVERA, AMANDA
Entity type:Individual
Prefix:
First Name:AMANDA
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 1:5407 9TH ST NW
Mailing Address - Street 2:APT 109
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20011-2920
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4320 SEMINARY RD
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22304-1535
Practice Address - Country:US
Practice Address - Phone:703-504-3090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-01
Last Update Date:2019-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024174875367500000X
DCRN1015599367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered