Healthcare Provider Details

I. General information

NPI: 1124594080
Provider Name (Legal Business Name): DOMINICA N ROBERTS FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/18/2018
Last Update Date: 03/27/2026
Certification Date: 03/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1890 WAITE ST
NORTH BEND OR
97459-1229
US

IV. Provider business mailing address

3810 BUCCANEER LN APT D
NORTH BEND OR
97459-2490
US

V. Phone/Fax

Practice location:
  • Phone: 541-756-6232
  • Fax:
Mailing address:
  • Phone: 541-756-6232
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number10042861
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95031253
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: