Provider Demographics
NPI:1508066903
Name:RIVERS, MARLEAH (CRNA)
Entity Type:Individual
Prefix:
First Name:MARLEAH
Middle Name:
Last Name:RIVERS
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:MARLEAH
Other - Middle Name:
Other - Last Name:OLIVER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:3709 GRAND PRIX DR
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30013-1480
Mailing Address - Country:US
Mailing Address - Phone:248-396-9628
Mailing Address - Fax:
Practice Address - Street 1:1670 CLAIRMONT RD
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033-4004
Practice Address - Country:US
Practice Address - Phone:404-329-6111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-23
Last Update Date:2015-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR163175-3367500000X
GARN158259163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN087978000Medicaid
MN087978000Medicaid