Provider Demographics
NPI:1417625187
Name:RIVERA RIVERA, STACY MARIE (AG-ACNP)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:MARIE
Last Name:RIVERA RIVERA
Suffix:
Gender:F
Credentials:AG-ACNP
Other - Prefix:
Other - First Name:STACY
Other - Middle Name:MARIE
Other - Last Name:TORRES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:AG-ACNP
Mailing Address - Street 1:6667 VALJEAN CT
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92111-5936
Mailing Address - Country:US
Mailing Address - Phone:352-474-9363
Mailing Address - Fax:
Practice Address - Street 1:415 N CRESCENT DR STE 320
Practice Address - Street 2:
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90210-6813
Practice Address - Country:US
Practice Address - Phone:888-803-3370
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-30
Last Update Date:2024-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11035492363LA2100X, 363LA2200X
CA95011538363LA2200X, 363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health