Healthcare Provider Details

I. General information

NPI: 1376889071
Provider Name (Legal Business Name): DR. ANASTASIA LEIGH RALSTON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MS. ANASTASIA LEIGH JORDAN

II. Dates (important events)

Enumeration Date: 12/27/2012
Last Update Date: 04/28/2023
Certification Date: 04/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1027 WASHINGTON AVE STE B
VINCENNES IN
47591-2240
US

IV. Provider business mailing address

1027 WASHINGTON AVE STE B
VINCENNES IN
47591-2240
US

V. Phone/Fax

Practice location:
  • Phone: 812-494-7500
  • Fax:
Mailing address:
  • Phone: 618-554-0259
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209010136
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: