Provider Demographics
NPI:1043483548
Name:JONES, ROBERTA LYNN (RN)
Entity Type:Individual
Prefix:MRS
First Name:ROBERTA
Middle Name:LYNN
Last Name:JONES
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:HC 75 BOX 172
Mailing Address - Street 2:
Mailing Address - City:NEW CREEK
Mailing Address - State:WV
Mailing Address - Zip Code:26743-9716
Mailing Address - Country:US
Mailing Address - Phone:304-788-2648
Mailing Address - Fax:
Practice Address - Street 1:1 BAKER PL
Practice Address - Street 2:
Practice Address - City:KEYSER
Practice Address - State:WV
Practice Address - Zip Code:26726-2824
Practice Address - Country:US
Practice Address - Phone:304-788-4200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-07
Last Update Date:2008-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV33046163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV9702095000Medicaid