Provider Demographics
NPI:1922497601
Name:RIVERA, STACEY (ARNP)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:RIVERA
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 E SOUTH ST STE 100
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32801-3508
Mailing Address - Country:US
Mailing Address - Phone:407-843-1180
Mailing Address - Fax:
Practice Address - Street 1:320 E SOUTH ST STE 100
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32801-3508
Practice Address - Country:US
Practice Address - Phone:407-843-1180
Practice Address - Fax:407-841-6160
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-17
Last Update Date:2025-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9277710363LF0000X
FLAPRN9277710363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL101498400Medicaid