Healthcare Provider Details

I. General information

NPI: 1609150598
Provider Name (Legal Business Name): MARY JACQUELINE ROBERTS APRN, FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/10/2011
Last Update Date: 02/26/2024
Certification Date: 02/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1465 N GARDNER ST
SCOTTSBURG IN
47170-7751
US

IV. Provider business mailing address

PO BOX 776351
CHICAGO IL
60677-6351
US

V. Phone/Fax

Practice location:
  • Phone: 812-752-0001
  • Fax: 812-752-0010
Mailing address:
  • Phone: 502-588-9408
  • Fax: 502-272-5116

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number3007173
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71004757A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: