MEDICARE: JANE ANNE ROBERTS RN, COTA/L

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	163W00000X	Registered Nurse	03-893788	CT
2	224Z00000X	Occupational Therapy Assistant	03-882186	CT
3	224Z00000X	Occupational Therapy Assistant	OTA 11327	FL

General Provider Information

NPI Number	:	1194035220
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JANE ANNE ROBERTS RN, COTA/L

Provider Business Mailing Address
First Line	:	232 CECELIA DR NW
Second Line	:
City	:	FORT WALTON BEACH
State	:	FL
Zip	:	32548-4714
Country	:	US
Telephone Number	:	860-303-3527
Fax Number	:

Provider Business Practice Location Address
First Line	:	232 CECELIA DR NW
Second Line	:
City	:	FORT WALTON BEACH
State	:	FL
Zip	:	32548-4714
Country	:	US
Telephone Number	:	860-303-3527
Fax Number	:

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

Provider Enumeration Date	:	10/07/2010
Last Update Date	:	10/07/2010

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