Healthcare Provider Details

I. General information

NPI: 1144410911
Provider Name (Legal Business Name): NIKKI LYNN ROBERTSON OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2007
Last Update Date: 03/29/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3101 SHANNON RD
DURHAM NC
27707-3571
US

IV. Provider business mailing address

7100 SIX FORKS RD SUITE 301
RALEIGH NC
27615-6156
US

V. Phone/Fax

Practice location:
  • Phone: 919-493-8508
  • Fax: 919-676-2231
Mailing address:
  • Phone: 919-847-0187
  • Fax: 919-676-2231

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number00004135
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2171
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: