1306201520 NPI number — MARISSA ROBERTS APRN-NP

Table of content: MARISSA ROBERTS APRN-NP (NPI 1306201520)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306201520 NPI number — MARISSA ROBERTS APRN-NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROBERTS
Provider First Name:
MARISSA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
APRN-NP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1306201520
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/29/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2147
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT MYERS
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33902-2147
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
239-343-3831
Provider Business Mailing Address Fax Number:
239-343-2301

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2780 CLEVELAND AVE STE 709
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT MYERS
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33901
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
239-343-3831
Provider Business Practice Location Address Fax Number:
239-343-2301
Provider Enumeration Date:
12/16/2015

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363L00000X , with the licence number:  ARNP9451478 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363L00000X , with the licence number: 3009938 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: ARNP9451478 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 019898000 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".