MEDICARE: MISS PRISCILLA RIVERA NP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LA2200X	Adult Health Nurse Practitioner	277.003527	IL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	F400179195	OTHER		MEDICARE PTAN

General Provider Information

NPI Number	:	1205116282
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS PRISCILLA RIVERA NP

Provider Business Mailing Address
First Line	:	PO BOX 746715
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30374-6715
Country	:	US
Telephone Number	:	773-352-1515
Fax Number	:	312-929-0373

Provider Business Practice Location Address
First Line	:	6918 W ARCHER AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60638-2337
Country	:	US
Telephone Number	:	773-667-3508
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/23/2011
Last Update Date	:	06/06/2025

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