1295010114 NPI number — AMBER DAWN ROBERTSON

Table of content: AMBER DAWN ROBERTSON (NPI 1295010114)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295010114 NPI number — AMBER DAWN ROBERTSON

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROBERTSON
Provider First Name:
AMBER
Provider Middle Name:
DAWN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ARRANT
Provider Other First Name:
AMBER
Provider Other Middle Name:
DAWN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
APRN
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1295010114
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/01/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
21 GLADNEY LOOP
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RAYVILLE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
71269-5536
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
318-372-2707
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2913 BETIN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MONROE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71201-7257
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-388-1250
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/12/2011

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: 363LF0000X , with the licence number:  AP06545 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363LF0000X , with the licence number: APO6545 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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