MEDICARE: MRS. GWENITA ROBERTS FNP-C

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	578285	TX
2	363L00000X	Nurse Practitioner	578285	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	7149594	OTHER	TX	AETNA
2	NP7128	OTHER	TX	BLUE CROSS BLUE SHIELD
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	562313709	OTHER	TX	UNITED HEALTHCARE
6	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
7	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
8	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
9	8Y1837	OTHER	TX	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1629093455
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. GWENITA ROBERTS FNP-C

Provider Business Mailing Address
First Line	:	3436 S POLK ST
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75224-3804
Country	:	US
Telephone Number	:	214-372-9200
Fax Number	:	214-372-9201

Provider Business Practice Location Address
First Line	:	3436 S POLK ST
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75224-3804
Country	:	US
Telephone Number	:	214-372-9200
Fax Number	:	214-372-9201

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

Provider Enumeration Date	:	07/13/2006
Last Update Date	:	10/24/2022

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Directions to “ MRS. GWENITA ROBERTS FNP-C” Practice Location

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