Healthcare Provider Details

I. General information

NPI: 1720784796
Provider Name (Legal Business Name): ALYSSA RIVERA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/01/2023
Last Update Date: 11/15/2023
Certification Date: 07/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 E RIDGEWOOD AVE SUITE 208
RIDGEWOOD NJ
07450
US

IV. Provider business mailing address

1200 E RIDGEWOOD AVE SUITE 208
RIDGEWOOD NJ
07450
US

V. Phone/Fax

Practice location:
  • Phone: 201-444-0868
  • Fax: 201-493-0797
Mailing address:
  • Phone: 201-444-0868
  • Fax: 201-493-0797

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberF12220228
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: