Healthcare Provider Details

I. General information

NPI: 1255265708
Provider Name (Legal Business Name): ILYA RIVKIN PMHNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/10/2026
Last Update Date: 06/10/2026
Certification Date: 06/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18555 OCEAN MIST DR
BOCA RATON FL
33498-4907
US

IV. Provider business mailing address

18555 OCEAN MIST DR
BOCA RATON FL
33498-4907
US

V. Phone/Fax

Practice location:
  • Phone: 347-446-1616
  • Fax:
Mailing address:
  • Phone: 347-446-1616
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number11048258
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: