Healthcare Provider Details

I. General information

NPI: 1073237202
Provider Name (Legal Business Name): JUANITA MARIE ROBERTS FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2022
Last Update Date: 09/30/2022
Certification Date: 09/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1625 E JEFFERSON BLVD
MISHAWAKA IN
46545-7103
US

IV. Provider business mailing address

406 S WASHINGTON ST
PIERCETON IN
46562-9341
US

V. Phone/Fax

Practice location:
  • Phone: 574-255-1400
  • Fax:
Mailing address:
  • Phone: 574-253-5994
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71013131A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: