Healthcare Provider Details

I. General information

NPI: 1992795744
Provider Name (Legal Business Name): MS. MARY B ROBERTS
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/24/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 TWINING STREET
MAXWELL AFB AL
36112
US

IV. Provider business mailing address

752 WHITEHALL PKWY
MONTGOMERY AL
36109-2212
US

V. Phone/Fax

Practice location:
  • Phone: 334-953-5143
  • Fax: 334-953-8296
Mailing address:
  • Phone: 334-260-0882
  • Fax: 334-953-8296

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License Number14043
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: