Healthcare Provider Details

I. General information

NPI: 1134585680
Provider Name (Legal Business Name): LISSETTE RIVAS LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/13/2016
Last Update Date: 01/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 SIERRA VISTA LANE
VALLEY COTTAGE NY
10989
US

IV. Provider business mailing address

405 SIERRA VISTA LANE
VALLEY COTTAGE NY
10989
US

V. Phone/Fax

Practice location:
  • Phone: 845-220-2146
  • Fax: 845-220-2121
Mailing address:
  • Phone: 845-220-2146
  • Fax: 845-220-2121

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number250282-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: