Provider Demographics
NPI:1730447970
Name:RIVERA, IRAIDA
Entity type:Individual
Prefix:
First Name:IRAIDA
Middle Name:
Last Name:RIVERA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1523 ALHAMBRA AVE
Mailing Address - Street 2:
Mailing Address - City:MARTINEZ
Mailing Address - State:CA
Mailing Address - Zip Code:94553-2403
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3333 CHANATE RD
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95404-1707
Practice Address - Country:US
Practice Address - Phone:707-565-4935
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-25
Last Update Date:2017-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA796084163WP0808X
CA95008058363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health