Healthcare Provider Details

I. General information

NPI: 1174290910
Provider Name (Legal Business Name): MICHELLE RAE RIVERA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2021
Last Update Date: 06/25/2024
Certification Date: 06/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10631 S 51ST ST STE 8
PHOENIX AZ
85044-5225
US

IV. Provider business mailing address

10901 E PUEBLO AVE
MESA AZ
85208-3907
US

V. Phone/Fax

Practice location:
  • Phone: 480-418-7246
  • Fax:
Mailing address:
  • Phone: 480-467-8169
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number265613
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberRN158234
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: