Provider Demographics
NPI:1306186341
Name:RIVERA, DARLY IVETTE
Entity type:Individual
Prefix:MISS
First Name:DARLY
Middle Name:IVETTE
Last Name:RIVERA
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:PO BOX 510
Mailing Address - Street 2:
Mailing Address - City:LAS PIEDRAS
Mailing Address - State:PR
Mailing Address - Zip Code:00771-0510
Mailing Address - Country:US
Mailing Address - Phone:787-562-0953
Mailing Address - Fax:
Practice Address - Street 1:702 CALLE ROOSEVELT
Practice Address - Street 2:APTO.102
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00907-3449
Practice Address - Country:US
Practice Address - Phone:787-562-0953
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-28
Last Update Date:2013-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1674133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR$$$$$$$$$Medicaid