Healthcare Provider Details

I. General information

NPI: 1306941158
Provider Name (Legal Business Name): CAROLYN ROBERTSON APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/14/2006
Last Update Date: 12/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11601 WILSHIRE BLVD 5TH FLOOR
LOS ANGELES CA
90025-0509
US

IV. Provider business mailing address

2355 N PYRITE
MESA AZ
85207-2509
US

V. Phone/Fax

Practice location:
  • Phone: 516-834-0564
  • Fax: 646-843-4764
Mailing address:
  • Phone: 480-357-0018
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code364SM0705X
TaxonomyMedical-Surgical Clinical Nurse Specialist
License Number214530
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code364SM0705X
TaxonomyMedical-Surgical Clinical Nurse Specialist
License Number2753
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code364SM0705X
TaxonomyMedical-Surgical Clinical Nurse Specialist
License NumberAP3296
License Number StateAZ
# 4
Primary TaxonomyN
Taxonomy Code364SM0705X
TaxonomyMedical-Surgical Clinical Nurse Specialist
License NumberNC99530
License Number StateNJ
# 5
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number704002
License Number StateCA
# 6
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN1555154
License Number StateAZ
# 7
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberNR 99530
License Number StateNJ
# 8
Primary TaxonomyY
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License Number214530
License Number StateNY
# 9
Primary TaxonomyN
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License Number704002
License Number StateCA
# 10
Primary TaxonomyN
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License Number214530
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: