Healthcare Provider Details

I. General information

NPI: 1558442061
Provider Name (Legal Business Name): PAMELA JEAN RIVERA PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/18/2006
Last Update Date: 11/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 CRATER LAKE AVE
MEDFORD OR
97504-7444
US

IV. Provider business mailing address

15 CRATER LAKE AVE
MEDFORD OR
97504-7444
US

V. Phone/Fax

Practice location:
  • Phone: 541-770-5100
  • Fax: 541-770-5070
Mailing address:
  • Phone: 541-770-5100
  • Fax: 541-770-5070

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number200650041NP
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: