Provider Demographics
NPI:1770152175
Name:RIVERA, KIMBERLY AROMY (FNP)
Entity type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:AROMY
Last Name:RIVERA
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5032 HOUSE SPARROW DR
Mailing Address - Street 2:
Mailing Address - City:MADISONVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70447-3032
Mailing Address - Country:US
Mailing Address - Phone:985-640-1043
Mailing Address - Fax:
Practice Address - Street 1:835 PRIDE DR STE B
Practice Address - Street 2:
Practice Address - City:HAMMOND
Practice Address - State:LA
Practice Address - Zip Code:70401-9527
Practice Address - Country:US
Practice Address - Phone:985-543-4333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-21
Last Update Date:2023-09-14
Deactivation Date:2021-06-29
Deactivation Code:
Reactivation Date:2021-09-30
Provider Licenses
StateLicense IDTaxonomies
LA220156363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA220156Medicaid