Healthcare Provider Details

I. General information

NPI: 1225741762
Provider Name (Legal Business Name): RODRIKE QUENTRELL ROBERTS DNP, FNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/29/2022
Last Update Date: 08/20/2026
Certification Date: 08/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4937 OLD COUNTRY CLUB RD
WINSTON SALEM NC
27104-5071
US

IV. Provider business mailing address

PO BOX 60447
CHARLOTTE NC
28260-0447
US

V. Phone/Fax

Practice location:
  • Phone: 336-718-4510
  • Fax:
Mailing address:
  • Phone: 336-718-4510
  • Fax: 336-718-4519

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number5017523
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number5017523
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code363LC1500X
TaxonomyCommunity Health Nurse Practitioner
License Number5017523
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: