Healthcare Provider Details

I. General information

NPI: 1588094825
Provider Name (Legal Business Name): MARK ROBERTS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/23/2013
Last Update Date: 10/14/2024
Certification Date: 10/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

122 WYOMING ST
DAYTON OH
45409-2731
US

IV. Provider business mailing address

1846 SPINDLETOP LN
DAYTON OH
45458-6501
US

V. Phone/Fax

Practice location:
  • Phone: 937-223-4461
  • Fax: 937-449-7603
Mailing address:
  • Phone: 937-991-3188
  • Fax: 937-223-9811

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberPN151753-M-IV
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAPRN.CNP.0027441
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPRN.CNP.0027441
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: