Provider Demographics
NPI:1124723390
Name:RIVERA, MALLORY RENEE (NP)
Entity type:Individual
Prefix:MRS
First Name:MALLORY
Middle Name:RENEE
Last Name:RIVERA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 WILSON RD STE 100
Mailing Address - Street 2:
Mailing Address - City:MONTEREY
Mailing Address - State:CA
Mailing Address - Zip Code:93940-7885
Mailing Address - Country:US
Mailing Address - Phone:831-649-1000
Mailing Address - Fax:
Practice Address - Street 1:501 LIGHTHOUSE AVE
Practice Address - Street 2:
Practice Address - City:MONTEREY
Practice Address - State:CA
Practice Address - Zip Code:93940-1439
Practice Address - Country:US
Practice Address - Phone:831-649-0770
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-04
Last Update Date:2023-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95024093363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily