MEDICARE: MICHELLE JEAN ROBERTS FNP, PMHNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	200550161NP	OR
2	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	201250209NP	OR

General Provider Information

NPI Number	:	1023066446
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHELLE JEAN ROBERTS FNP, PMHNP

Provider Business Mailing Address
First Line	:	1722 NW RALEIGH ST. SUITE 211 / MBX 410
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97209-1753
Country	:	US
Telephone Number	:	971-282-2346
Fax Number	:	971-228-1382

Provider Business Practice Location Address
First Line	:	1722 NW RALEIGH ST. SUITE 211 / MBX 410
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97209-1753
Country	:	US
Telephone Number	:	971-282-2346
Fax Number	:	971-228-1382

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/05/2006
Last Update Date	:	08/04/2015

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