1366073041 NPI number — COURTNEY WHITE ROBERSON NP

Table of content: COURTNEY WHITE ROBERSON NP (NPI 1366073041)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366073041 NPI number — COURTNEY WHITE ROBERSON NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROBERSON
Provider First Name:
COURTNEY
Provider Middle Name:
WHITE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
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:
1366073041
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/04/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
160 W. UNIVERSITY PKWY, SUITE C
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSON
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
38305
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
731-286-1510
Provider Business Mailing Address Fax Number:
731-286-1510

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1575 PARR AVE, SUITE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DYERSBURG
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38024
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
731-286-1510
Provider Business Practice Location Address Fax Number:
731-286-1510
Provider Enumeration Date:
01/30/2020

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:  27094 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2025 www.npivalidator.com