Healthcare Provider Details

I. General information

NPI: 1508336389
Provider Name (Legal Business Name): DALICE BALLOU ROBERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2018
Last Update Date: 09/06/2022
Certification Date: 09/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1419 CUMBERLAND FALLS HWY
CORBIN KY
40701-2722
US

IV. Provider business mailing address

1214 SCENIC VIEW HTS
CORBIN KY
40701-2188
US

V. Phone/Fax

Practice location:
  • Phone: 606-528-4481
  • Fax:
Mailing address:
  • Phone: 606-261-1443
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: