Healthcare Provider Details

I. General information

NPI: 1043652803
Provider Name (Legal Business Name): LISA SHEA ROBERTS F.N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2013
Last Update Date: 06/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 E 100 N SUITE 303
LOGAN UT
84321-4661
US

IV. Provider business mailing address

12965 W 61ST CIR
ARVADA CO
80004-3981
US

V. Phone/Fax

Practice location:
  • Phone: 435-760-7078
  • Fax:
Mailing address:
  • Phone: 435-760-7078
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number8689112-4405
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number8689112-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: