Healthcare Provider Details

I. General information

NPI: 1619123478
Provider Name (Legal Business Name): REBECCA L ROBERTS CNP,CDE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2008
Last Update Date: 09/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

136 S LUDLOW ST FL. 1
DAYTON OH
45402-1813
US

IV. Provider business mailing address

400 SUGAR CAMP CIR SUITE 205
OAKWOOD OH
45409-1963
US

V. Phone/Fax

Practice location:
  • Phone: 937-499-8273
  • Fax: 937-223-9811
Mailing address:
  • Phone: 937-395-3656
  • Fax: 937-395-3657

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number291690
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberNP-10474
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License NumberRN291690
License Number StateOH
# 4
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberCOA.10474-NP
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: