Healthcare Provider Details

I. General information

NPI: 1295791309
Provider Name (Legal Business Name): NANCY DENNISSE RIVERA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: NANCY DENNISSE RIVERA-KING M.D.

II. Dates (important events)

Enumeration Date: 04/26/2006
Last Update Date: 06/15/2021
Certification Date: 06/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1209A MARDA LN
ANNAPOLIS MD
21403-1706
US

IV. Provider business mailing address

20 MAYO RD STE 201
EDGEWATER MD
21037-1442
US

V. Phone/Fax

Practice location:
  • Phone: 410-353-9323
  • Fax: 410-877-6807
Mailing address:
  • Phone: 410-956-6800
  • Fax: 410-956-6803

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberD0040904
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: