Healthcare Provider Details

I. General information

NPI: 1619690112
Provider Name (Legal Business Name): MADELINE MOCK ROBERTS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2022
Last Update Date: 04/04/2023
Certification Date: 04/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

603 E LAMAR ST
AMERICUS GA
31709-3737
US

IV. Provider business mailing address

603 E LAMAR ST
AMERICUS GA
31709-3737
US

V. Phone/Fax

Practice location:
  • Phone: 229-928-3444
  • Fax: 229-928-3446
Mailing address:
  • Phone: 229-928-3444
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN271855
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License NumberRN271855
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: