=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215434584
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LIBRA ROBERTSON CRNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/12/2018
-----------------------------------------------------
Last Update Date | 05/22/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 E PENNSYLVANIA AVE STE 304
-----------------------------------------------------
City | TOWSON
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21286-0701
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-498-4808
-----------------------------------------------------
Fax | 410-498-7244
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6405 CHESSINGTON ST
-----------------------------------------------------
City | MIDDLE RIVER
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21220-1857
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 443-743-8129
-----------------------------------------------------
Fax | 410-498-7244
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | R208116
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 163W00000X
-----------------------------------------------------
Taxonomy Name | Registered Nurse
-----------------------------------------------------
License Number | R208116
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 363LP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Nurse Practitioner
-----------------------------------------------------
License Number | R208116
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------