Healthcare Provider Details

I. General information

NPI: 1588576896
Provider Name (Legal Business Name): AMANDA ROBERTS
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2026
Last Update Date: 09/21/2026
Certification Date: 09/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

97 E BLANCHARD RD
SHEPHERD MI
48883-9705
US

IV. Provider business mailing address

97 E BLANCHARD RD
SHEPHERD MI
48883-9705
US

V. Phone/Fax

Practice location:
  • Phone: 989-621-6373
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number4703107661
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: