Provider Demographics
NPI:1497255491
Name:ANDERSON, VIVA RENA
Entity Type:Individual
Prefix:MRS
First Name:VIVA
Middle Name:RENA
Last Name:ANDERSON
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:PO BOX 743
Mailing Address - Street 2:
Mailing Address - City:RULEVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38771-0743
Mailing Address - Country:US
Mailing Address - Phone:662-545-8263
Mailing Address - Fax:
Practice Address - Street 1:401 W SUNFLOWER ST APT 9
Practice Address - Street 2:
Practice Address - City:RULEVILLE
Practice Address - State:MS
Practice Address - Zip Code:38771-3819
Practice Address - Country:US
Practice Address - Phone:662-545-8263
Practice Address - Fax:662-545-8263
Is Sole Proprietor?:No
Enumeration Date:2018-02-15
Last Update Date:2018-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS70285376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide