1720405939 NPI number — MRS. HEIDI NICOLE RIVIELLO PA-C

Table of content: MRS. HEIDI NICOLE RIVIELLO PA-C (NPI 1720405939)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720405939 NPI number — MRS. HEIDI NICOLE RIVIELLO PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RIVIELLO
Provider First Name:
HEIDI
Provider Middle Name:
NICOLE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BRESCIA
Provider Other First Name:
HEIDI
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA-C
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1720405939
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/15/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1033 US HIGHWAY 46 STE 102
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLIFTON
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07013-2448
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
973-799-7979
Provider Business Mailing Address Fax Number:
973-799-7970

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
171 LAKE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RAMSEY
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07446-2089
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
17-850-0112
Provider Business Practice Location Address Fax Number:
201-785-9100
Provider Enumeration Date:
03/25/2014

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363AM0700X , with the licence number:  3159 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363AM0700X , with the licence number: MP00599500 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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