Provider Demographics
NPI:1174186795
Name:RIVERA, ANAIS IVETTE
Entity type:Individual
Prefix:
First Name:ANAIS
Middle Name:IVETTE
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 1:5104 FIDDLEWOOD WAY
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:FL
Mailing Address - Zip Code:34771-8594
Mailing Address - Country:US
Mailing Address - Phone:407-421-1431
Mailing Address - Fax:
Practice Address - Street 1:4201 NOLTE RD
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:FL
Practice Address - Zip Code:34772-7158
Practice Address - Country:US
Practice Address - Phone:407-780-7317
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-18
Last Update Date:2019-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA15865224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant