Provider Demographics
NPI:1912292236
Name:RIVERA-JORGE, LISSETTE JOSEPHINE (RD, LD/N)
Entity Type:Individual
Prefix:MS
First Name:LISSETTE
Middle Name:JOSEPHINE
Last Name:RIVERA-JORGE
Suffix:
Gender:F
Credentials:RD, LD/N
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4441 SW 160 COURT
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33185-4938
Mailing Address - Country:US
Mailing Address - Phone:305-226-3081
Mailing Address - Fax:305-226-1631
Practice Address - Street 1:4441 SW 160 COURT
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33185-4938
Practice Address - Country:US
Practice Address - Phone:305-226-3081
Practice Address - Fax:305-226-1631
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-15
Last Update Date:2011-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND 3813133NN1002X, 133V00000X
FLND3813133VN1005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1005XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Renal
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered