MEDICARE: ADELLA STACY ROBERTS

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	163WM0705X	Medical-Surgical Registered Nurse	585132	NY

General Provider Information

NPI Number	:	1063752087
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ADELLA STACY ROBERTS

Provider Business Mailing Address
First Line	:	230 PACIFIC ST
Second Line	:	APT 7
City	:	BROOKLYN
State	:	NY
Zip	:	11201-5731
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	230 PACIFIC ST
Second Line	:	APT 7
City	:	BROOKLYN
State	:	NY
Zip	:	11201-5731
Country	:	US
Telephone Number	:	917-586-4898
Fax Number	:

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

Provider Enumeration Date	:	02/28/2013
Last Update Date	:	02/28/2013

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