MEDICARE: MS. REBECCA L ROBERTS CNP,CDE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	291690	OH
2	363LF0000X	Family Nurse Practitioner	NP-10474	OH
3	163WD0400X	Diabetes Educator Registered Nurse	RN291690	OH
4	363LA2200X	Adult Health Nurse Practitioner	COA.10474-NP	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000000599279	OTHER	OH	BCBS OHIO
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	421534506138	OTHER	OH	CARESOURCE OHIO

General Provider Information

NPI Number	:	1619123478
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. REBECCA L ROBERTS CNP,CDE

Provider Business Mailing Address
First Line	:	400 SUGAR CAMP CIR
Second Line	:	SUITE 205
City	:	OAKWOOD
State	:	OH
Zip	:	45409-1963
Country	:	US
Telephone Number	:	937-395-3656
Fax Number	:	937-395-3657

Provider Business Practice Location Address
First Line	:	136 S LUDLOW ST
Second Line	:	FL. 1
City	:	DAYTON
State	:	OH
Zip	:	45402-1813
Country	:	US
Telephone Number	:	937-499-8273
Fax Number	:	937-223-9811

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/13/2008
Last Update Date	:	09/16/2015

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