Healthcare Provider Details

I. General information

NPI: 1497008189
Provider Name (Legal Business Name): KELLY VANESSA RIVERA APRN-CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2012
Last Update Date: 05/09/2025
Certification Date: 05/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10416 MORNING STAR DR NE
ALBUQUERQUE NM
87111-7539
US

IV. Provider business mailing address

PO BOX 90644
ALBUQUERQUE NM
87199-0644
US

V. Phone/Fax

Practice location:
  • Phone: 214-227-2457
  • Fax: 214-764-0880
Mailing address:
  • Phone: 214-227-2457
  • Fax: 214-764-0880

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number57165
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: