Provider Demographics
NPI:1912477027
Name:RIVERA, LOURDES M (APRN)
Entity Type:Individual
Prefix:
First Name:LOURDES
Middle Name:M
Last Name:RIVERA
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:LOURDES
Other - Middle Name:MARIA
Other - Last Name:RIVERA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:AANP-BC
Mailing Address - Street 1:9601 PULASKI PARK DR STE 417
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21220-1409
Mailing Address - Country:US
Mailing Address - Phone:410-933-5678
Mailing Address - Fax:
Practice Address - Street 1:6480 WATERLOO RD
Practice Address - Street 2:
Practice Address - City:ELKRIDGE
Practice Address - State:MD
Practice Address - Zip Code:21075-6508
Practice Address - Country:US
Practice Address - Phone:410-799-0291
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-01
Last Update Date:2023-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDAC004543363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily