Provider Demographics
NPI:1174104582
Name:RIVERA LOPEZ, FREDERIED (FNP-BC)
Entity type:Individual
Prefix:
First Name:FREDERIED
Middle Name:
Last Name:RIVERA LOPEZ
Suffix:
Gender:M
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:360 DOUGLAS AVE
Mailing Address - Street 2:
Mailing Address - City:ALTAMONTE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32714-3335
Mailing Address - Country:US
Mailing Address - Phone:407-788-8200
Mailing Address - Fax:407-788-3746
Practice Address - Street 1:737 SOUTH SEMORAN BLVD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32807
Practice Address - Country:US
Practice Address - Phone:407-693-2819
Practice Address - Fax:407-264-6936
Is Sole Proprietor?:No
Enumeration Date:2021-04-16
Last Update Date:2023-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11012492363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily