Healthcare Provider Details

I. General information

NPI: 1013915966
Provider Name (Legal Business Name): AMY L ROBERTS CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2005
Last Update Date: 12/14/2020
Certification Date: 12/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 W 27TH ST
LUMBERTON NC
28358-3075
US

IV. Provider business mailing address

3100 SPRING FOREST RD SUITE 130
RALEIGH NC
27616-2880
US

V. Phone/Fax

Practice location:
  • Phone: 843-661-6215
  • Fax:
Mailing address:
  • Phone: 919-882-0705
  • Fax: 919-873-9821

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number128131
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number1967A
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: