MEDICARE: MS. PAULETTE ROBERTS FNP

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	F339552-1	NY

General Provider Information

NPI Number	:	1174918494
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. PAULETTE ROBERTS FNP

Provider Business Mailing Address
First Line	:	13749 SOUTHGATE ST
Second Line	:
City	:	SPRINGFIELD GARDENS
State	:	NY
Zip	:	11413-2628
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	13749 SOUTHGATE ST
Second Line	:
City	:	SPRINGFIELD GARDENS
State	:	NY
Zip	:	11413-2628
Country	:	US
Telephone Number	:	646-644-3622
Fax Number	:

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

Provider Enumeration Date	:	04/02/2015
Last Update Date	:	04/02/2015

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