MEDICARE: MRS. ERIN EILEEN RIVERA PHD, CNS, APRN, BC

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	364SG0600X	Gerontology Clinical Nurse Specialist	70000103A	IN
2	364S00000X	Clinical Nurse Specialist	70000103A	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1790893147
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. ERIN EILEEN RIVERA PHD, CNS, APRN, BC

Provider Business Mailing Address
First Line	:	415 E COOK RD
Second Line	:	SUITE 100
City	:	FORT WAYNE
State	:	IN
Zip	:	46825-3636
Country	:	US
Telephone Number	:	260-489-6030
Fax Number	:	260-489-5536

Provider Business Practice Location Address
First Line	:	415 E COOK RD
Second Line	:	SUITE 100
City	:	FORT WAYNE
State	:	IN
Zip	:	46825-3636
Country	:	US
Telephone Number	:	260-489-6030
Fax Number	:	260-489-5536

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

Provider Enumeration Date	:	08/27/2006
Last Update Date	:	04/04/2012

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