Healthcare Provider Details

I. General information

NPI: 1891870390
Provider Name (Legal Business Name): GRACE WAYNETTE RIVES R.N.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/25/2006
Last Update Date: 08/10/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

956 US HIGHWAY 27 SOUTH
MOORE HAVEN FL
33471
US

IV. Provider business mailing address

59 E PARK AVE. S.E.
MOORE HAVEN FL
33471
US

V. Phone/Fax

Practice location:
  • Phone: 863-946-0707
  • Fax:
Mailing address:
  • Phone: 863-946-1548
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number3410352
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: