Provider Demographics
NPI:1033677190
Name:ROBERTS, DEEDRA ELIZABETH (FNP)
Entity Type:Individual
Prefix:MS
First Name:DEEDRA
Middle Name:ELIZABETH
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:MS
Other - First Name:ELIZABETH
Other - Middle Name:
Other - Last Name:ROBERTS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:NP
Mailing Address - Street 1:5353 MISSION CENTER RD STE 300
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-1305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5655 CAMINITO DANZARIN
Practice Address - Street 2:
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-7161
Practice Address - Country:US
Practice Address - Phone:512-466-2087
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-07
Last Update Date:2019-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95011012363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily