Healthcare Provider Details

I. General information

NPI: 1396889721
Provider Name (Legal Business Name): AMY RUTH ROBERTSON FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/18/2007
Last Update Date: 01/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2520 5TH ST N
COLUMBUS MS
39705-2008
US

IV. Provider business mailing address

98 LAKESHORE DR
COLUMBUS MS
39705-1712
US

V. Phone/Fax

Practice location:
  • Phone: 662-244-1000
  • Fax:
Mailing address:
  • Phone: 662-329-3698
  • Fax: 662-240-1949

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR701335
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: