Provider Demographics
NPI:1194117259
Name:RIVERA, SANDRA DEJESUS (CRNP)
Entity type:Individual
Prefix:MRS
First Name:SANDRA
Middle Name:DEJESUS
Last Name:RIVERA
Suffix:
Gender:
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 SPRUCE ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-5701
Mailing Address - Country:US
Mailing Address - Phone:800-789-7366
Mailing Address - Fax:215-340-3575
Practice Address - Street 1:777 TOWNSHIP LINE ROAD
Practice Address - Street 2:2ND FLOOR
Practice Address - City:YARDLEY
Practice Address - State:PA
Practice Address - Zip Code:19067-5564
Practice Address - Country:US
Practice Address - Phone:800-789-7366
Practice Address - Fax:215-340-3575
Is Sole Proprietor?:No
Enumeration Date:2015-02-26
Last Update Date:2025-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP014643363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily