Basic Information
| Provider Information | |||||||||
| NPI: | 1518503796 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RIVERA | ||||||||
| FirstName: | JENNIFER | ||||||||
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| Credential: | RN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1300 MICCOSUKEE RD | ||||||||
| Address2: | |||||||||
| City: | TALLAHASSEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 323085054 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8504311155 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2807 CAPITAL MEDICAL BLVD STE 2 | ||||||||
| Address2: | |||||||||
| City: | TALLAHASSEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 323088420 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8504024107 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/21/2019 | ||||||||
| LastUpdateDate: | 10/04/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | RN9308857 | FL | N | Nursing Service Providers | Registered Nurse | 363L00000X | 11015368 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.