Healthcare Provider Details

I. General information

NPI: 1154832574
Provider Name (Legal Business Name): RAQUEL IVET RIVAS FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: RAQUEL IVET FOX FNP-C

II. Dates (important events)

Enumeration Date: 10/12/2017
Last Update Date: 06/22/2021
Certification Date: 06/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4110 N 108TH AVE STE 105
PHOENIX AZ
85037-5772
US

IV. Provider business mailing address

4110 N 108TH AVE STE 105
PHOENIX AZ
85037-5772
US

V. Phone/Fax

Practice location:
  • Phone: 623-772-6999
  • Fax: 623-772-6444
Mailing address:
  • Phone: 623-772-6999
  • Fax: 623-772-6444

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP10626
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: