Provider Demographics
NPI:1063612489
Name:RIVERA, DEBORA LYNN (LPN)
Entity type:Individual
Prefix:MS
First Name:DEBORA
Middle Name:LYNN
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 1:80 WALBRIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:BAY SHORE
Mailing Address - State:NY
Mailing Address - Zip Code:11706-3054
Mailing Address - Country:US
Mailing Address - Phone:631-968-4176
Mailing Address - Fax:
Practice Address - Street 1:80 WALBRIDGE AVE
Practice Address - Street 2:
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-3054
Practice Address - Country:US
Practice Address - Phone:631-968-4176
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-23
Last Update Date:2007-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY240236164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse