Provider Demographics
NPI:1053299958
Name:RIVAS-VELAZQUEZ, GINA MARIE
Entity type:Individual
Prefix:
First Name:GINA
Middle Name:MARIE
Last Name:RIVAS-VELAZQUEZ
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 1:22 KORWEL CIR
Mailing Address - Street 2:
Mailing Address - City:WEST ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07052-1208
Mailing Address - Country:US
Mailing Address - Phone:201-259-5424
Mailing Address - Fax:
Practice Address - Street 1:26 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:EAST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07017-1315
Practice Address - Country:US
Practice Address - Phone:201-259-5424
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-26
Last Update Date:2025-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ373H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes373H00000XNursing Service Related ProvidersDay Training/Habilitation SpecialistGroup - Multi-Specialty