Provider Demographics
NPI:1003119538
Name:ROBERTSON, SHAYLA R (IDC)
Entity Type:Individual
Prefix:
First Name:SHAYLA
Middle Name:R
Last Name:ROBERTSON
Suffix:
Gender:F
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 ALLEN ST
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23505-1373
Mailing Address - Country:US
Mailing Address - Phone:850-497-6656
Mailing Address - Fax:
Practice Address - Street 1:150 ALLEN ST
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23505-1373
Practice Address - Country:US
Practice Address - Phone:850-497-6656
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-05
Last Update Date:2010-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRV0136141710I1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman