Provider Demographics
NPI:1447919030
Name:RIVAS, SHANELLY (APRN, FNP-C)
Entity type:Individual
Prefix:
First Name:SHANELLY
Middle Name:
Last Name:RIVAS
Suffix:
Gender:F
Credentials:APRN, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1239 MEISSEN AVE NW
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32907-1037
Mailing Address - Country:US
Mailing Address - Phone:321-525-6476
Mailing Address - Fax:
Practice Address - Street 1:1239 MEISSEN AVE NW
Practice Address - Street 2:
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32907-1037
Practice Address - Country:US
Practice Address - Phone:321-525-6476
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-11
Last Update Date:2021-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLF12210010363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily