Provider Demographics
NPI:1265018212
Name:RIVERS, ANASTACIA ROSETTA (LPN)
Entity Type:Individual
Prefix:
First Name:ANASTACIA
Middle Name:ROSETTA
Last Name:RIVERS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:ANASTACIA
Other - Middle Name:
Other - Last Name:WILLIAMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:523 SW 11TH ST
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73501-4701
Mailing Address - Country:US
Mailing Address - Phone:915-433-5801
Mailing Address - Fax:
Practice Address - Street 1:523 SW 11TH ST
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73501-4701
Practice Address - Country:US
Practice Address - Phone:915-433-5801
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-21
Last Update Date:2021-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKLPN096160164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse