Healthcare Provider Details

I. General information

NPI: 1982581369
Provider Name (Legal Business Name): DIMITRIA D. ROBERTS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/19/2025
Last Update Date: 05/07/2026
Certification Date: 05/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1050 BIG JOE RD
MONTICELLO FL
32344-5188
US

IV. Provider business mailing address

4157 CORINTH CHURCH RD
LAKE PARK GA
31636-2921
US

V. Phone/Fax

Practice location:
  • Phone: 678-699-5401
  • Fax:
Mailing address:
  • Phone: 678-699-5401
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number281634
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: