Healthcare Provider Details

I. General information

NPI: 1063332088
Provider Name (Legal Business Name): SHONDERRIA L ROBERTS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SHONDERRIA L POPE

II. Dates (important events)

Enumeration Date: 07/20/2026
Last Update Date: 07/20/2026
Certification Date: 06/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40032 RODEO DR
HAMILTON MS
39746-9690
US

IV. Provider business mailing address

40032 RODEO DR
HAMILTON MS
39746-9690
US

V. Phone/Fax

Practice location:
  • Phone: 662-640-1507
  • Fax:
Mailing address:
  • Phone: 662-640-1507
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number907385
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: