Provider Demographics
NPI:1568486298
Name:RIVERA, MILDRED (NP)
Entity type:Individual
Prefix:MS
First Name:MILDRED
Middle Name:
Last Name:RIVERA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MS
Other - First Name:MILDRED
Other - Middle Name:
Other - Last Name:RIVERA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ARNP
Mailing Address - Street 1:11685 ALPHARETTA HWY STE 380
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30076-4988
Mailing Address - Country:US
Mailing Address - Phone:770-619-5100
Mailing Address - Fax:404-250-8067
Practice Address - Street 1:11685 ALPHARETTA HWY STE 380
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-4988
Practice Address - Country:US
Practice Address - Phone:770-619-5100
Practice Address - Fax:404-250-8067
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2024-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN1867732363LA2200X
GA235057363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLQ12934Medicare UPIN
FLU23372Medicare ID - Type UnspecifiedMEDICARE