Healthcare Provider Details

I. General information

NPI: 1083968978
Provider Name (Legal Business Name): TAMRA R ROBERTSON CPNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TAMRA R EHLTS CPNP

II. Dates (important events)

Enumeration Date: 10/31/2012
Last Update Date: 05/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 S LANDMARK AVE
BLOOMINGTON IN
47403-5001
US

IV. Provider business mailing address

PO BOX 1329
BLOOMINGTON IN
47402-1329
US

V. Phone/Fax

Practice location:
  • Phone: 812-335-2434
  • Fax: 812-335-7604
Mailing address:
  • Phone: 812-353-3087
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number71006229A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number209-009796
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: