Provider Demographics
NPI:1174366561
Name:RIVERA GONZALEZ, VANNESA
Entity type:Individual
Prefix:MRS
First Name:VANNESA
Middle Name:
Last Name:RIVERA GONZALEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:VANNESA
Other - Middle Name:
Other - Last Name:GONZALEZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1393 WEIMER RD
Mailing Address - Street 2:
Mailing Address - City:TAOS
Mailing Address - State:NM
Mailing Address - Zip Code:87571-6201
Mailing Address - Country:US
Mailing Address - Phone:575-741-0370
Mailing Address - Fax:
Practice Address - Street 1:1393 WEIMER RD
Practice Address - Street 2:
Practice Address - City:TAOS
Practice Address - State:NM
Practice Address - Zip Code:87571-6201
Practice Address - Country:US
Practice Address - Phone:575-741-0370
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-14
Last Update Date:2024-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMG-1509172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker