Healthcare Provider Details

I. General information

NPI: 1528217445
Provider Name (Legal Business Name): ANDREA ROBERTS LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2008
Last Update Date: 09/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45 S 3RD AVE
AVONDALE AZ
85323-2264
US

IV. Provider business mailing address

45 S 3RD AVE
AVONDALE AZ
85323-2264
US

V. Phone/Fax

Practice location:
  • Phone: 623-772-5110
  • Fax: 623-772-5120
Mailing address:
  • Phone: 623-772-5110
  • Fax: 623-772-5120

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberLP039220
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: