Provider Demographics
NPI:1841620218
Name:RIVERA, SALLIE JO (FNP-BC, MSN, CIC)
Entity type:Individual
Prefix:
First Name:SALLIE
Middle Name:JO
Last Name:RIVERA
Suffix:
Gender:F
Credentials:FNP-BC, MSN, CIC
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 1705
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30903-1705
Mailing Address - Country:US
Mailing Address - Phone:706-724-7263
Mailing Address - Fax:706-774-7230
Practice Address - Street 1:325 GEORGIA AVE STE 200
Practice Address - Street 2:
Practice Address - City:NORTH AUGUSTA
Practice Address - State:SC
Practice Address - Zip Code:29841-3848
Practice Address - Country:US
Practice Address - Phone:803-442-5750
Practice Address - Fax:803-442-5751
Is Sole Proprietor?:No
Enumeration Date:2013-11-20
Last Update Date:2020-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN267435363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL206147OtherMEDICARE PTAN (GROUP)
ILF400129560OtherMEDICARE PTAN (INDIVIDUAL)