Healthcare Provider Details

I. General information

NPI: 1912159781
Provider Name (Legal Business Name): ROBERTA SMITH RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ROBERTA ANN FREELAND LPN

II. Dates (important events)

Enumeration Date: 10/10/2008
Last Update Date: 10/22/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2700 STEWART PARKWAY ANNEX B
ROSEBURG OR
97471
US

IV. Provider business mailing address

272 MEDICAL LOOP SUITE E
ROSEBURG OR
97471
US

V. Phone/Fax

Practice location:
  • Phone: 541-440-3532
  • Fax: 541-440-3554
Mailing address:
  • Phone: 541-440-3532
  • Fax: 541-440-3554

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number200040188RN
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: