Healthcare Provider Details

I. General information

NPI: 1841921012
Provider Name (Legal Business Name): MS. SHARESE ROBERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2022
Last Update Date: 06/20/2022
Certification Date: 06/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

816 E 25TH ST
PANAMA CITY FL
32405-5219
US

IV. Provider business mailing address

816 E 25TH ST
PANAMA CITY FL
32405-5219
US

V. Phone/Fax

Practice location:
  • Phone: 850-532-7096
  • Fax:
Mailing address:
  • Phone: 850-532-7096
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License NumberR1627936260
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: