Healthcare Provider Details

I. General information

NPI: 1588103337
Provider Name (Legal Business Name): KELLI ANNA RIVERA LAT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/13/2017
Last Update Date: 08/06/2026
Certification Date: 08/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2475 W NARANJA DR
ORO VALLEY AZ
85742-9733
US

IV. Provider business mailing address

7355 S WILMOT RD UNIT 3307
TUCSON AZ
85756-0157
US

V. Phone/Fax

Practice location:
  • Phone: 520-696-3902
  • Fax:
Mailing address:
  • Phone: 608-225-3800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2400-39
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number100114
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberS536-5019-7635-05
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: