Healthcare Provider Details

I. General information

NPI: 1457629628
Provider Name (Legal Business Name): ELIZABETH ANN ROBERTS RNBSN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/02/2011
Last Update Date: 12/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 SHONNARD ST
SYRACUSE NY
13204-3216
US

IV. Provider business mailing address

5341 STRAWFLOWER DR
N SYRACUSE NY
13212-1242
US

V. Phone/Fax

Practice location:
  • Phone: 315-435-4973
  • Fax: 315-435-4934
Mailing address:
  • Phone: 315-435-4973
  • Fax: 315-435-4934

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number354368-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: