Provider Demographics
NPI:1407632656
Name:RIVERA, MODESTA GUILLERMINA
Entity type:Individual
Prefix:
First Name:MODESTA
Middle Name:GUILLERMINA
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 1:1327 WINTER GARDEN VINELAND RD STE 130
Mailing Address - Street 2:
Mailing Address - City:WINTER GARDEN
Mailing Address - State:FL
Mailing Address - Zip Code:34787-4363
Mailing Address - Country:US
Mailing Address - Phone:407-452-8466
Mailing Address - Fax:
Practice Address - Street 1:1327 WINTER GARDEN VINELAND RD
Practice Address - Street 2:
Practice Address - City:WINTER GARDEN
Practice Address - State:FL
Practice Address - Zip Code:34787-4363
Practice Address - Country:US
Practice Address - Phone:321-422-2303
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-05
Last Update Date:2024-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11028419363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty