Healthcare Provider Details

I. General information

NPI: 1578455598
Provider Name (Legal Business Name): CAROL ROBERTS
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2025
Last Update Date: 07/15/2025
Certification Date: 07/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

51 WILLIAM B GRAHAM CT
KILMARNOCK VA
22482-3852
US

IV. Provider business mailing address

257 TUCKER POINT LN
CALLAO VA
22435-2137
US

V. Phone/Fax

Practice location:
  • Phone: 804-435-0575
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number0001124953
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: