Provider Demographics
NPI:1215334255
Name:RIVERA-DEJESUS, NADIA LIA
Entity type:Individual
Prefix:
First Name:NADIA
Middle Name:LIA
Last Name:RIVERA-DEJESUS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1823 MADISON ST
Mailing Address - Street 2:10
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11385-3750
Mailing Address - Country:US
Mailing Address - Phone:646-287-4706
Mailing Address - Fax:
Practice Address - Street 1:1823 MADISON ST
Practice Address - Street 2:10
Practice Address - City:RIDGEWOOD
Practice Address - State:NY
Practice Address - Zip Code:11385-3750
Practice Address - Country:US
Practice Address - Phone:646-287-4706
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-19
Last Update Date:2014-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY694583174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist