Provider Demographics
NPI:1255390381
Name:RIVERS, CHARISSE LENELL (NP)
Entity type:Individual
Prefix:
First Name:CHARISSE
Middle Name:LENELL
Last Name:RIVERS
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 1:9991 MARSH LN
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75220-1766
Mailing Address - Country:US
Mailing Address - Phone:214-358-0090
Mailing Address - Fax:214-526-6851
Practice Address - Street 1:9991 MARSH LN
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75220-1766
Practice Address - Country:US
Practice Address - Phone:214-358-0090
Practice Address - Fax:214-358-0760
Is Sole Proprietor?:No
Enumeration Date:2006-03-18
Last Update Date:2015-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX522465363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX042485506Medicaid
TX042485504Medicaid
8C6798Medicare ID - Type Unspecified
TX042485504Medicaid
TX042485506Medicaid