Provider Demographics
NPI:1548793631
Name:DEROUSSEL, ANASTASIA (NP)
Entity Type:Individual
Prefix:
First Name:ANASTASIA
Middle Name:
Last Name:DEROUSSEL
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 W CHEROKEE ST
Mailing Address - Street 2:
Mailing Address - City:WAGONER
Mailing Address - State:OK
Mailing Address - Zip Code:74467-4624
Mailing Address - Country:US
Mailing Address - Phone:918-485-5514
Mailing Address - Fax:
Practice Address - Street 1:1202 W CHEROKEE ST STE G
Practice Address - Street 2:
Practice Address - City:WAGONER
Practice Address - State:OK
Practice Address - Zip Code:74467-4629
Practice Address - Country:US
Practice Address - Phone:918-914-5533
Practice Address - Fax:918-485-6020
Is Sole Proprietor?:No
Enumeration Date:2017-04-06
Last Update Date:2023-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY727314-1163W00000X
NYF341382-1363LF0000X
OKR0129494363LG0600X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology