Healthcare Provider Details

I. General information

NPI: 1548480890
Provider Name (Legal Business Name): LINDA SHODD ROBERTS CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/27/2007
Last Update Date: 08/31/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 E DOWNING ST SUITE 208
TAHLEQUAH OK
74464-3234
US

IV. Provider business mailing address

300 PENDLETON ST
TAHLEQUAH OK
74464-2219
US

V. Phone/Fax

Practice location:
  • Phone: 918-446-2496
  • Fax: 918-456-7108
Mailing address:
  • Phone: 918-457-7515
  • Fax: 918-456-7108

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License NumberR0059260
License Number StateOK

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
IdentifierR00559260
Identifier TypeOTHER
Identifier StateOK
Identifier IssuerOK NURSING LICENSE
# 2
Identifier200308880A
Identifier TypeMEDICAID
Identifier StateOK
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: