MEDICARE: MRS. KIMBERLI IDONA ROBERTS RN

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	RN196355	GA

General Provider Information

NPI Number	:	1316194178
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KIMBERLI IDONA ROBERTS RN

Provider Business Mailing Address
First Line	:	2901 BRIDLE CREEK DR SW
Second Line	:
City	:	CONYERS
State	:	GA
Zip	:	30094-5697
Country	:	US
Telephone Number	:	202-549-7496
Fax Number	:

Provider Business Practice Location Address
First Line	:	5935 CORNERSTONE CT W
Second Line	:	SUITE 300
City	:	SAN DIEGO
State	:	CA
Zip	:	92121-3737
Country	:	US
Telephone Number	:	866-687-7390
Fax Number	:

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

Provider Enumeration Date	:	08/24/2008
Last Update Date	:	08/24/2008

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